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|Ministry of Health

and Long-Term Care

Homes for Special Care

|Home for Special Care (HSC)

Licence Inspection Report

| |

|Instructions: |

|If space is insufficient, attach additional sheet. |

|Each section of the report must be completed. |

|Where there is non-compliance, compliance requirement and date must be included on report. |

|Do not use white out. |

|Changes to report need to be made prior to signatures and changes should be initialed by HSC Field Staff and Homeowner. |

|Report must be provided to Ministry of Health and Long-Term Care by December 31. |

|Copy of inspection report to be provided to licensed homeowner. |

|Name of Home |Home License Number |

|      |      |

|Address of Home |Telephone (incl. Area Code) |Licensed HSC Capacity |

|      |      |      |

|Name of Licensed Homeowner |

|      |

|Address of Licensed Homeowner |Telephone (incl. Area Code) |

|      |      |

|Name of Manager/Operator (if different from owner) |

|      |

|Address of Manager/Operator |Telephone (incl. Area Code) |

|      |      |

|HSC Staff Conducting Review |HSC Office |Date of Inspection (yyyy/mm/dd) |

|      |      |      |

|Who resides in the Home? Check appropriate boxes |

| Owner Manager/Operator Home Staff | Children’s Ages: |   |/ |   |/ |   |

| Other (Specify) |

|      |

|HSC Residents: |Other: (non-HSC Residents) |

|   |Male |

|Accommodation Provided |

| |   | |   |

|Number of Bedrooms with One Tenant per Bedroom: | |Number of Bedrooms with Two Tenants per Bedroom: | |

| |   | |   |

|Number of Bedrooms with Three Tenants per Bedroom: | |Number of Bedrooms with Four Tenants per Bedroom : | |

| |      |

|Other – Please describe: | |

| |

|Original – Ministry of Health and Long-Term Care; Copy – Homes for Special Care Office |

| HSC Licence Inspection Report |

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|The following are to be reviewed when inspecting an HSC for licence purposes. |

| |

|YES = compliance and satisfactory NO = non-compliance and requires improvement/correction |

|Residential Environment |

|Physical Environment and Health and Safety Issues |

|Fire and Safety | N | Y | Compliance Requirements and Date | Notes |

|Does the Home have a fire safety plan in place | | |      |      |

|specifying Home Staff’s duties in the event of a fire?| | | | |

|Are monthly fire drills completed? | | |      |      |

|Are location of fire exits known to residents and Home| | |      |      |

|Staff? | | | | |

|Are hallways and stairways clear of debris and well | | |      |      |

|lit? | | | | |

|Bedrooms | N | Y | Compliance Requirements and Date | Notes |

|Are the tenants’ bedrooms located at or above the | | |      |      |

|ground floor? | | | | |

|Are bedrooms adequate in size? | | |      |      |

|(not less than 60 sq.ft./5.57m2 ) | | | | |

|Are the bedrooms adequately ventilated | | |      |      |

|and lit by natural light? | | | | |

|Is each bed placed so as not to overlap a window or | | |      |      |

|radiator, and at least 30” from another bed? | | | | |

|Do windows have appropriate coverings? | | |      |      |

|Do the tenants have access to their bedrooms at all | | |      |      |

|times? | | | | |

|Is the furniture sufficient for the number of tenants | | |      |      |

|in the room? | | | | |

|Are bedroom furniture, floors and mattresses clean and| | |      |      |

|in good repair? | | | | |

|Are bedrooms, including floors, vacuumed and cleaned | | |      |      |

|on a regular basis? | | | | |

|Are tenants permitted to decorate their bedrooms and | | |      |      |

|have they decorated them? | | | | |

|Rooms, Floors, Stairs, Landings | N | Y | Compliance Requirements and Date | Notes |

|Is there a common indoor sitting area provided with | | |      |      |

|24-hour access? | | | | |

|Is there a minimum of one television provided | | |      |      |

|for tenant’s use in the common area? | | | | |

|Is there adequate lighting in the common area? | | |      |      |

|Do the common and dining areas adequately accommodate | | |      |      |

|all of the tenants? | | | | |

| HSC Licence Inspection Report |

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|Rooms, Floors, Stairs, Landings | N | Y | Compliance Requirements and Date | Notes |

|Are the common and dining areas and furniture clean | | |      |      |

|and in good repair (wallpaper, paint and flooring)? | | | | |

|Is the general environment of rooms bright and | | |      |      |

|cheerful? | | | | |

|Is the Home equipped with handrails on stairways, | | |      |      |

|non-skid finishes and coverings on floors and | | | | |

|stairways? | | | | |

|Is the Home free of faulty floors or missing treads on| | |      |      |

|stairs or loose carpeting, which could cause tripping,| | | | |

|or slipping? | | | | |

| | | | | |

|Sanitary Facilities | N | Y | Compliance Requirements and Date | Notes |

|Are all sanitary facilities working and in good | | |      |      |

|repair? | | | | |

|Do the tenants have 24-hour access to the bathrooms | | |      |      |

|and are they easily accessible with privacy? | | | | |

|Is every tub and shower facility furnished with grab | | |      |      |

|bars and slip resistant material that adheres to the | | | | |

|bottom of tub/shower? | | | | |

|Are wash basins, toilets, urinals, bath tubs and | | |      |      |

|shower stalls cleaned and sanitized once every day and| | | | |

|are wastebaskets emptied regularly? | | | | |

|Are residents provided with adequate supplies of | | |      |      |

|personal grooming/hygiene items? | | | | |

|Are hot water tanks set at 60 degrees Celsius (140 | | |      |      |

|degrees Fahrenheit) and the water temperature | | | | |

|controlled at fixture outlets/faucets controlled so | | | | |

|water temperature does not exceed 49 degrees Celsius | | | | |

|(120.2 degrees Fahrenheit)? | | | | |

|Is the ratio of tenant use to basins, tubs and toilets| | |      |      |

|sufficient to meet the needs of the tenants (1 flush | | | | |

|toilet/6 tenants; 1 bath tub or shower for every 12 | | | | |

|tenants)? | | | | |

|Towels, Linens, Laundry | N | Y | Compliance Requirements and Date | Notes |

|Are there sufficient clean towels, washcloths and bed | | |      |      |

|linens available to all tenants and are these changed | | | | |

|at lease once per week? | | | | |

|Are laundry receptacles for soiled laundry | | |      |      |

|provided? | | | | |

|Are laundry services provided to the tenants? | | |      |      |

|Is there access to the washer, dryer, iron and ironing| | |      |      |

|board and laundry supplies for those tenants who | | | | |

|choose and are able to do their own laundry? | | | | |

|Is the laundry equipment clean and in good working | | |      |      |

|order? | | | | |

| HSC Licence Inspection Report |

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|Windows, Ventilation, Lighting, Heating | N | Y | Compliance Requirements and Date | Notes |

|Is there adequate ventilation in all rooms to minimize| | |      |      |

|excess heat and odours? | | | | |

|Is the home in compliance with the Smoke-Free Ontario | | |      |      |

|Act? (i.e. Home to be smoke free unless there is a | | | | |

|controlled smoking area in the home which has been | | | | |

|approved by the Ministry of Health and Long-Term | | | | |

|Care.) | | | | |

|Do all windows that open have an attached | | |      |      |

|screen in proper working order and coverings | | | | |

|(i.e. shades, blinds and curtains)? | | | | |

|Is adequate lighting provided throughout the Home’s | | |      |      |

|hallways, stairways, landings, and ramps and at all | | | | |

|entrances and exits? | | | | |

|Is the temperature of the Home kept comfortable (i.e. | | |      |      |

|minimum 21 C [69.8F] in winter and at least one air | | | | |

|conditioned room in periods of extreme heat in | | | | |

|summer)? | | | | |

|Kitchen Facilities/Food Preparation | N | Y | Compliance Requirements and Date | Notes |

|Are kitchen countertops and other food preparation | | |      |      |

|surfaces kept clean? | | | | |

|Are the eating and cooking utensils clean and in good | | |      |      |

|condition (i.e. no cracked or chipped dishes)? | | | | |

|Are Home Staff knowledgeable in food preparation? | | |      |      |

|Is a satisfactory standard of dishwashing used? | | |      |      |

|Are separate cutting boards used? (1 for raw | | |      |      |

|meats, seafood, 2nd for poultry and turkey | | | | |

|and 3rd for raw fruits and vegetables)? | | | | |

|Are there adequate kitchen equipment, supplies and | | |      |      |

|food storage area? | | | | |

|Are cleaning, toxic and hazardous materials stored | | |      |      |

|separately from supplies and clearly labelled? | | | | |

|Are there convenient hand washing facilities provided | | |      |      |

|in or near the kitchen and are clean hand towels and | | | | |

|napkins provided? | | | | |

|Are perishable foods refrigerated as required? | | |      |      |

|Garbage Receptacles, Screening | N | Y | Compliance Requirements and Date | Notes |

|Is all garbage contained in receptacles that are | | |      |      |

|covered with tight-fitting lids? | | | | |

|Are the premises adequately protected | | |      |      |

|And screened against rodents, flies and | | | | |

|other pests? | | | | |

|Outdoor Area | N | Y | Compliance Requirements and Date | Notes |

|Is the outdoor area of the Home well maintained, free | | |      |      |

|of debris and in good repair? | | | | |

|Is an outdoor seating area for seasonal use provided | | |      |      |

|which is comfortable and adequate for the number of | | | | |

|tenants in the Home? | | | | |

| HSC Licence Inspection Report |

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|General Health |

|Nutrition | N | Y | Compliance Requirements and Date | Notes |

|Does the meal plan meet the “recommended daily intake”| | |      |      |

|for energy essential nutrients as stated in Canada’s | | | | |

|Food Guide, including the availability of fresh fruits| | | | |

|and vegetables? | | | | |

|Are adequate portions and variety of foods provided | | |      |      |

|(according to individual needs)? | | | | |

|Are tenants consulted during meal planning? | | |      |      |

|Are special diets provided (i.e. cultural, physician | | |      |      |

|ordered and preferences)? | | | | |

|Are meals provided on a flexible time schedule? | | |      |      |

|Are nutritional snacks provided for tenants? | | |      |      |

|Are packed lunches or late meals provided or saved for| | |      |      |

|tenants when advanced notice is given? | | | | |

|Are menus posted? | | |      |      |

|Personal Care | N | Y | Compliance Requirements and Date | Notes |

|Are tenants who require assistance, assisted with | | |      |      |

|personal care (i.e. hygiene and grooming)? | | | | |

|Is information and teaching about personal care | | |      |      |

|available for residents? | | | | |

|Are tenants provided with the opportunity to | | |      |      |

|individually purchase clothing? | | | | |

|Medical/Dental Care | N | Y | Compliance Requirements and Date | Notes |

|Do tenants have personal physicians? | | |      |      |

|Do tenants receive yearly physical examinations? | | |      |      |

|Do Home Staff handle emergency situations in a timely | | |      |      |

|and appropriate manner (i.e. contact relevant people)?| | | | |

|Do tenants get regular dental care? | | |      |      |

|Medication | N | Y | Compliance Requirements and Date | Notes |

|Is medication stored in a locked cabinet? | | |      |      |

|Does the Home have an appropriate system | | |      |      |

|of medication management (i.e. blister packs | | | | |

|and MAR sheets)? | | | | |

|Does the Home maintain a list of contents for drug | | |      |      |

|cabinets and update them on a regular basis (weekly)? | | | | |

|Does the Home Owner/Home Staff monitor and report | | |      |      |

|noted unusual behaviour possibly linked to side | | | | |

|effects of medication? | | | | |

| HSC Licence Inspection Report |

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|Communicable Diseases | N | Y | Compliance Requirements and Date | Notes |

|Does the Home use routine practices | | |      |      |

|(infection control precautions) to promote | | | | |

|infection control? | | | | |

|Emergency Care | N | Y | Compliance Requirements and Date | Notes |

|Does the Home have appropriate procedures in place to | | |      |      |

|respond to emergency care situations? | | | | |

|Are Home Staff trained in first aid measures and CPR | | |      |      |

|available at all times in the home? | | | | |

|Are tenants familiar with emergency procedures? | | |      |      |

|Are first aid kits available and updated on a regular | | |      |      |

|basis? | | | | |

|Tenant Lifestyles |

|Race and Culture, Religious Expression, Sexuality | N | Y | Compliance Requirements and Date | Notes |

|Are tenants’ rights regarding race, culture, religion | | |      |      |

|and sexuality respected by the Homeowner/Home Staff? | | | | |

|Privacy | N | Y | Compliance Requirements and Date | Notes |

|Are tenants’ rights respected and promoted (i.e. | | |      |      |

|privacy in bedrooms, to visit with visitors, unopened | | | | |

|mail, and private telephone calls)? | | | | |

|Is the home accessible to tenants on a | | |      |      |

|24 hour basis? | | | | |

|Are tenants free to enter and leave the Home at their | | |      |      |

|choosing? | | | | |

|Is there an organized forum available for tenants to | | |      |      |

|raise concerns (i.e. house meeting)? | | | | |

|Daily Living |

|Life Skills, Social and Recreational Programs |

|In-Home Living Activities | N | Y | Compliance Requirements and Date | Notes |

|Does the Home provide adequate/appropriate in-home | | |      |      |

|activities? | | | | |

|Do tenants have an opportunity to participate in the | | |      |      |

|development of life skills within the home? | | | | |

|Activity Programs in the Community | N | Y | Compliance Requirements and Date | Notes |

|Does the Homeowner/Home staff assist the tenant in | | |      |      |

|participating in community activities (i.e. fitness, | | | | |

|community programs)? | | | | |

|Tenants’ Spending Money | N | Y | Compliance Requirements and Date | Notes |

|Are tenants aware of their financial status and | | |      |      |

|matters of estate? | | | | |

|Does the Home maintain appropriate books | | |      |      |

|and records for those tenants who are | | | | |

|assisted with their spending money? | | | | |

| HSC Licence Inspection Report |

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|Administration |

|Staffing |

|List the names of Home Staff: |

|      |

|Staffing | N | Y | Compliance Requirements and Date | Notes |

|Is there Home Staff on duty 24 hours a day? | | |      |      |

|Is tenant supervision satisfactory to meet tenant | | |      |      |

|needs with current staffing level? | | | | |

|Is the local HSC office informed prior to staff | | |      |      |

|changes and criminal reference checks (CPICs) acquired| | | | |

|for all new staff? | | | | |

|Is there appropriate and satisfactory communication | | |      |      |

|between the Home Staff and residents and HSC Field | | | | |

|Staff? | | | | |

|Are Home Staff adequately supervised? | | |      |      |

|Is job orientation and relevant training provided for | | |      |      |

|all home staff? | | | | |

|Licensing | N | Y | Compliance Requirements and Date | Notes |

|Are fire inspections completed and provided to HSC | | |      |      |

|Field Office by Nov. 15 of each year? | | | | |

|Does the homeowner report to have adequate insurance | | |      |      |

|as set out in the Operating Guidelines for HSC? | | | | |

|Does the homeowner report to have CPICs (including | | |      |      |

|vulnerable sector screening) for him/herself, spouse, | | | | |

|and any person the homeowner has in the home who has | | | | |

|unsupervised access to tenants? Are CPICs updated on | | | | |

|a 3 year cycle? | | | | |

|Records, Confidentiality, Conflicts, Conflict | N | Y | Compliance Requirements and Date | Notes |

|Resolution | | | | |

|Does the Home Owner keep appropriate records as per | | |      |      |

|the Operating Guidelines for HSC? | | | | |

|Are documents and records pertaining to tenants stored| | |      |      |

|in a locked and secure cabinet? | | | | |

|Does homeowner/home staff understand confidentiality | | |      |      |

|requirements and consents? | | | | |

|Are there written/verbal complaint procedures in place| | |      |      |

|in the home? | | | | |

|Is homeowner/home staff free of conflicts of interest | | |      |      |

|as set out in the Operating Guidelines for HSC? | | | | |

| HSC Licence Inspection Report |

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|Reporting Requirements | N | Y | Compliance Requirements and Date | Notes |

|Does the home have procedures for serious | | |      |      |

|incidents/occurrences (including notifying police)? | | | | |

|Does the homeowner report all serious incidents in | | |      |      |

|time (within 24 hours)? | | | | |

|Emergencies |

|Abuse and Neglect | N | Y | Compliance Requirements and Date | Notes |

|Does the homeowner provide a home environment free | | |      |      |

|from emotional, physical, financial, verbal or sexual | | | | |

|abuse? | | | | |

|Does the homeowner ensure that each tenant is not | | |      |      |

|subject to neglect and is provided with necessary | | | | |

|food, clothing, services, care and assistance required| | | | |

|for health and safety and well-being? | | | | |

|General |

|Does the homeowner/home staff show an understanding of| | |      |      |

|the Operating Guidelines for HCS and requirements of | | | | |

|the HSC program? | | | | |

|Does the homeowner have a copy of, or access to, the | | |      |      |

|Operating Guidelines for HSC, including appendices? | | | | |

| |

|Instructions |

|Once inspection report is completed, it must be signed by the homeowner and HSC field staff. |

|Licence recommendations can only be made once areas of non-compliance have been rectified. |

|This report have been reviewed by: |

|Signature of Homeowner |Print Name of Homeowner |

|x |      |

|Date (yyyy/mm/dd) |

|      |

|Comments of Homeowner |

|      |

|Signature of HSC Field Staff |Print Name of HSC Field Staff |

|x |      |

|Signature of HSC Field Staff |Print Name of HSC Field Staff |

|x |      |

|Comments of HSC Field Staff |

|      |

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