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Penny Lane

Confidential · Residential Care - Licensing

7 inspections

  1. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): August 29, 2025 Contravention - It was determined that the licensee did not maintain records of reportable incidents involving youth in care, as required. Failure to maintain records of reportable incidents could lead to inadequate follow up of safety issues and/or identify patterns of concern which may increase the risk of poor health and safety outcomes for the youth in care. The Licensee will submit a Compliance Plan to Licensing by September 19, 2025 confirming that the non-compliance with maintaining a record of reportable incidents has been corrected and include the system that will be implemented for ongoing compliance. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance. The Manager reported that they will begin to correct the contravention immediately.
      • R4.5M - Retain a record of reportable incidents involving persons in care; 88(c)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): August 29, 2025 Contravention - It is apparent by the contraventions noted in this report that the Licensee does not have systems in place to self-monitor the noted sections of the RCR to ensure compliance with the legislation. Failure to self-monitor for compliance with the legislation may increase risk to youth in care's health and safety, as their care needs may not be met. The Licensee will submit a Compliance Plan to Licensing by September 19, 2025 confirming that the non-compliance with self-monitoring has been corrected and include the system that will be implemented for ongoing self monitoring of the physical environment, and the care and services provided to persons in care. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance. The Manager reported that they will begin to correct the contravention immediately.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R4.6 - Are facility records current and complete?
      • Observation(s): August 29, 2025 Contravention - Repeat contravention from a Routine Inspection conducted on January 30, 2024. The Licensee did not have a copy of the last Medication Safety and Advisory Committee (MSAC) meeting minutes readily available on site. Without accessible copies of the MSAC meeting procedures there may be increased risk to youth in care due to possible medication mis-management. The Licensee will submit a Compliance Plan to Licensing by September 19, 2025 confirming that the non-compliance with policies and procedures has been corrected and include the system that will be implemented to ensure MSAC meeting minutes are retained, reviewed, and readily available .The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance. The Manager reported that they will begin to correct the contravention immediately.
      • R4.6A - Keep a copy of each policy and procedure of the medication safety and advisory committee; 85 ( 3 )
  2. Routine Inspection

    1 infraction

    • R4.6 - Are facility records current and complete?
      • Observation(s): January 30, 2024 Contravention - The Licensee changed their facility pharmacy approximately one year ago. The pharmacy does conduct meetings with the facility and audits of medication administration however, a system is not currently in place to ensure that meeting minutes are obtained from the Medication Safety and Advisory Committee meetings, reviewed, and retained. The Program Manager reported that a system will be put into place immediately.
      • R4.6A - Keep a copy of each policy and procedure of the medication safety and advisory committee; 85 ( 3 )
  3. Routine Inspection

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): February 10, 2020 The Licensee does not have systems in place to monitor for compliance with the legislation as it pertains to care plans containing all of the legislated requirements, new managers being orientated to previous inspections and existing compliance plans, ensuring that water temperature meets the legislation, and that hazardous materials are not available to youth in care. During the inspection the Manager stated that a plan is in place to orientate all new staff to the Residential Care Regulation, and that a plan and checklist will be put into place to ensure that all current staff will review the Residential Care Regulation and will be informed of the compliance plans that have been put in place in response to contraventions noted during previous and current inspections.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): February 10, 2020 The Manager reported that there is not a system in place to ensure that the water accessible to youth in care does not exceed 49 degrees Celsius. The water temperature was measured during the inspection and found to be 54 degrees Celsius. The Manager put a plan into place immediately to ensure that the water temperature is regulated. During the May 11, 2018 inspection the then Manager stated that the monitoring of the water temperature would be added to the monthly audit system, however a review of the monthly audit checklist showed that checking the water temperature was not on the form. It was noted during the inspection that bleach was accessible to youth in care if they were working in the laundry room. The Manager reported that the bleach will be moved and stored in a permanently locked location. It was discussed during the inspection that bags of donations were temporarily located in a hall that leads to an emergency exit. Although the emergency exit was not blocked, the Manager reported that effective immediately the donation bags will be stored elsewhere so that the hallway is completely empty.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 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): February 10, 2020 It was noted during the inspection that the licensee's system to ensure that all of the legislated requirements for a care plan was ineffective. For example; some youth were missing photos and there was no documentation to indicate whether they had declined to have their photo taken or not, similarly with monthly weights, and some immunization screening was missing. All of the legislated requirements for a care plan were reviewed with the Manager.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
  4. Monitoring

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): May 11, 2018 -It was discussed that on May 4, 2018 Licensing could not contact a supervisor that day to gather additional information on a high risk reportable incident that had been reported to Licensing on May 3, 2018. The manager has a system in place for the reporting of reportable incidents. The manager identified 2 areas where the system broke down.
      • R3.1N - Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
  5. Monitoring

    2 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): February 22, 2017 -The facility did not have a plan in place to prevent the youth in care from falling or exiting through the upstairs bedroom windows.
      • R7.2C - Windows must be secured to prevent falls from, or exiting through, the window; 15 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): February 22, 2017 -It was discussed that the facility did not have a system in place to provide youth with identification and encourage youth to carry identification when leaving the facility in the event the youth may not be able to identify themselves due to accident or illness. The Manager reported that a plan will be put into place to provide and encourage youth to carry identification.
      • R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
  6. Monitoring

    6 infractions

    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): NEW INFRACTIONS from Jan. 28, 2016 -It was noted that a reportable incident had not been reported to Licensing -It was noted that 12 IRs had been submitted to Licensing in 2015 and that 7 (58%) were reported more than 2 days after the incident.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): OUTSTANDING from Jan. 23, 2015 -Unable to locate records of employee annual flu vaccinations. CORRECTED DURING INSPECTION - Masks were purchased and education provided to staff by the manager in order to comply with the MHO influenza control directive of November 2014.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 2.1 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): NEW INFRACTIONS from Jan. 28, 2016 -Unable to locate a policy for orientation of managers and employees to the Residential Care Regulations and the Community Care and Assisted Living Act. -Unable to locate a policy for the continuing education of managers.
      • Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
      • Ensure there are written policies and procedures for continuing education of managers and employees; 85( 2 )(c)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): NEW INFRACTIONS from Jan. 28, 2016 -It was noted that admission height and weight (or client's refusal) was not documented in 2 charts. -It was noted that a person in care's photograph could not be located in 2 charts.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): OUTSTANDING from Jan. 23, 2015 -Influenza information and prevention supplies are not available at the entrance. CORRECTED DURING INSPECTION - Masks were purchased and education provided to staff by the manager in order to comply with the MHO influenza control directive of November 2014.
      • Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): NEW INFRACTION from January 28, 2016 -It was noted that a means for identification (admission height and weight, and a photo) were not included in 2 charts.
      • Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
  7. Monitoring

    7 infractions

    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Reportable incidents which occurred offsite were not reported to licensing.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Unable to locate records of employee annual flu vaccinations.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (13)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): See Records and Reporting 4.1
    • 2.1 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): Unable to locate site-specific emergency plans for emergencies other than fire. Unable to locate emergency fan out list. Policies have not been reviewed in the past year. The majority of the policies have not been reviewed in more than five years. Manager states the policies are being reviewed at present and a new policy manual will be released this year. Ashtray containing cigarette butts noted on deck. Manager states a person in care was smoking in this area when he was injured and was unable to access the designated safe smoking area. Ashtray removed by manager during the inspection.
      • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51(1)(a)
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
      • Ensure policies are implemented by employees; 85(1)(d)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Unable to locate person in care immunization records.
      • Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78(1)(a) Director of Licensing Standards of Practice: Immunization records
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Personal hygiene items in both persons in care bathrooms noted to be unlabelled and stored without separation. Influenza information and prevention supplies are not available at the entrance. Unable to locate policy regarding influenza outbreak prevention.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 (13)
      • Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Walls noted to have damage and holes in two persons in care's bedrooms and in downstairs bathroom. Some patch repairs noted. OUTSTANDING from April 2014 Broken side tables/drawers in 3 person in care bedrooms. OUTSTANDING from April 2014 Blinds damaged in person in care bedrooms. OUTSTANDING from April 2014 Area around vent in person in care bedroom appears blackened. Large whole in kitchen cupboard door upstairs. Broken bedframe in person in care's bedroom. Manager states she has put in a grant proposal for new furnishings and provided inspector with a confirmation email at the time of inspection. Manager states she has plans for the interior of the building to be painted in the spring and provided inspector with a confirmation email at the time of inspection.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29(1) (a)