Skip to content
Loading map…

Guisachan

CONFIDENTIAL · Residential Care - Licensing

4 inspections

  1. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During conversations with the manager, it was noted that since the inspection in 2024 there were two incidents where a person in care had to be taken to a hotel overnight due to a piece of equipment breaking and becoming unusable. It was also noted that the kitchen had been renovated. Licensing was not notified of these service delivery problems, and no health and safety plans were received. Changes to routine, such as a hotel stay or construction within the home, may increase risk to persons in care. Submitting a reportable incident as required helps to ensure there is a plan in place to ensure the ongoing health, safety and dignity of persons in care during these events. Submit to Licensing by November 14, 2025, a plan which details how all reportable incidents will be submitted to Licensing. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R4.5G - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): While reviewing policies and procedures related to medication, it was noted that there was nothing to guide staff on how often a MSAC meeting should occur. Regular MSAC meetings are necessary to mitigate the risk to persons in care as they are an opportunity to discuss safe storage, review policies and procedures and bring up any concerns that may arise. When there is nothing to indicate how often this must occur, there is a risk that the meetings may get missed. Submit to Licensing by November 14, 2025, a plan which details how MSAC meetings will be conducted as per the policy and procedure. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Employee files were reviewed, and it was noted that one employee file did not include character references. Character references help to determine if the potential employee is of good character and has the personality, ability and temperament necessary to manage or work with persons in care, as per the requirement under sections 37(2)(a)(b) of the Residential Care Regulation (RCR). When character references are not obtained, it is difficult to assess if the applicant meets these requirements and may put persons in care at risk if employees are not adequately able to care for them. Submit to Licensing by November 14, 2025, a plan which details how employees will have character references obtained. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Multiple uncovered razors were observed to be mixed in, and laying on top of, toothbrushes in a person in care's bathroom. Incorrect storage of personal items, such as these items, can lead to cross contamination and increase risk of illness. Submit to Licensing by November 14, 2025, a plan which details how toothbrushes and razors will be correctly and safely stored to minimize risk of cross contamination. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
  2. Routine Inspection

    4 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee's system to ensure that each day persons in care receive 2 nutritious snacks with at least 2 food groups, was found to be ineffective. During the inspection, it was observed that the Licensee has a system to track snacks; however, the document only had 1 day completed for the month of August and that day included only 1 food group.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The Licensee's system to assist persons in care in maintaining health and hygiene was found to be ineffective. During the inspection, multiple disposable razors were observed to be mixed in, and laying on top of, toothbrushes in a bathroom. There were also no labels to advise who the razors and toothbrushes belonged to.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee's system to ensure all rooms and common areas are maintained in a good state of repair was found to be ineffective. During the inspection the following areas of concern were observed: -Baseboard in dining room coming away from the wall and a piece of paint/drywall was loose and coming off of wall. -Baseboards in main level bathroom noted to be dirty and dusty. -Multiple scuffs on walls throughout the common living and dining room areas. Some observed to be more than surface scuffs. -Walls in dining room noted to have gouges in them with the drywall exposed. -Wall in laundry/elevator room was noted to have significant damage with exposed drywall. -Laminate on kitchen counters was noted to be coming up and held down with masking tape. It was confirmed that none of these issues had been communicated to maintenance.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The Licensee's system to ensure care plans are updated after a change occurs was noted to be ineffective. During the inspection, it was noted that an update to avoid certain foods until a swallowing assessment could be completed, were not reflected in a person in care's care plan after a choking incident occurred. The Licensee does not have a system in place to ensure advice from a health care provider is sought if there is an unintentional change in weight. During the inspection, it was noted that a person in care had a change in weight but there was no evidence that a health provider was notified.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
      • R10.3R - Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(b)
  3. Routine Inspection

    2 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): During the inspection, it was observed that persons in care must access the laundry area in order to use the elevator and that this area does not have slip resistant flooring.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee's system to ensure that sleep and mood monitoring documentation is completed was found to be ineffective. During the inspection, five separate sleep and mood monitoring documents were reviewed and all five were found to be missing initials and/or information to indicate that the monitoring had been completed.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  4. Routine Inspection

    3 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing reviewed the menu plan. Breakfast and snacks are offered however, are not on the menu. A few of the meals on the menu do not contain 3 food groups.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing tested the hot water and noted it to be a safe temperature. The hot water system is digital however, there is no system in place to monitor the temperature to ensure it does not exceed 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing reviewed person in care's care plans. It was noted that an order to change dental care appointment frequency was not reflected in the oral health plan. The follow up appointment was scheduled at the time of the change.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)