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Section 15 of the Community Care and Assisted Living Act establishes the statutory duty of the licensing officer, to investigate all complaints that a community care facility does not fully meet the requirements of the Act and regulations. The fact that an investigation is underway does not mean that the licensee has done something wrong. There are several circumstances which may trigger an investigation, with the most common being a complaint or a reportable incident.

Why am I required to submit a health and safety plan?

When a complaint is received, licensing officers respond promptly to ensure the health and safety of the persons in care. A health and safety plan may be requested to address alleged non-compliance and potential risk to persons in care pending the outcome of the investigation. Licensees can submit a revised health and safety plan for review at any time during the investigation. The licensee will be advised as  soon as the health and safety plan is no longer required. Balancing the health and safety of persons in care, and the principles of administrative fairness for the rights of licensees is critical.

Follow this link to learn more about health and safety plans.

In most cases licensing staff are unable to share the source of complaints with the facility.  It is important for the facility staff to work cooperatively with licensing and focus on ensuring the health and safety of the persons in care rather than on the source of the complaint.

What happens during an investigation?

Depending on the type of concern or the potential risk to the persons in care, Licensing will determine the next steps of the Investigation Process.

The licensing officer will:

  • Discuss the content of the complaint or reportable incident with the licensee or manager and the need for a health and safety plan.
  • Gather and review evidence to determine if there was any non-compliance. Evidence can be gathered by conducting inspections, reviewing facility records, and by conducting interviews with staff, families, persons in care, or other relevant individuals.
  • Request assistance from Police, Ministry for Children and Family Development, Community Living BC, Mental Health and Substance Use or Residential and Contract Services.
  • Advise the licensee/manager of the ongoing status of the investigation.
  • Present the investigation findings to the licensee and provide them with the opportunity to review and respond to the information.
  • Request a response, additional information, or a compliance plan, where warranted. 

What is the licensee role during an investigation?

The licensee is expected to:

  • Implement and maintain an approved health and safety plan.
  • Ensure the health and safety plan remains in effect until advised.
  • Work cooperatively with their licensing officer.
  • Address any findings of the investigation in a timely and appropriate manner.

Licensees are responsible for the performance of their staff and as such may need to conduct their own investigation to satisfy their obligations as an employer. A licensee may wish to participate in an investigation to discharge this obligation, and participation is encouraged. This should be discussed with the investigator as early as possible. We are committed to working with licensees, but a joint investigation may not be appropriate in all cases.

Investigation timelines vary depending on; the complexity of the investigation, the number of concerns that need to be investigated, and the need to collaborate with other agencies. The findings from an investigation are based on the balance of probability – meaning the event was more likely to occur than to have not occurred. An investigation under the Community Care and Assisted Living Act does not need to have evidence and facts to prove beyond a reasonable doubt that an event occurred.

Our committment

We recognize that investigations are unsettling for everyone involved and can be especially difficult for persons in care and an implicated staff person. We commit to being transparent and fair, and to concluding the investigation as quickly as possible.

MoH     PCQO