On a Friday afternoon in February, a raging fire swept through a foster home near Lindsay, Ont., trapping a 14-year-old resident and two caregivers in a second-floor bedroom.

The teenager, Kassy Finbow, and one of the caregivers, Andrea Reid, were killed.

“My daughter was supposed to be in a safe place and, in the end, it’s what took her precious life,” Kassy’s distraught mother, Chantal Finbow, told the Star. “Kassy was a beautiful young lady with so much potential.”

A sliding glass door in the room in which Kassy and Reid were found was bolted shut, the Star has learned. And the only window — in a gable off the roof — was too small for the surviving caregiver to escape. She was saved by firefighters who smashed through the window’s upper sash, according to the foster home’s operator, Bob Connor.

A 17-year-old resident of the rural foster home for girls has been charged with two counts of second-degree murder and one count of arson causing bodily harm in the Feb. 24 fire on Quaker Rd. in Oakwood.

The deaths have triggered multiple investigations about lax or non-existent provincial standards governing group homes and foster homes run by private companies. The OPP, Queen’s Park, children’s aid and Ontario’s child and youth advocate are finding plenty of blame to go around.

Read more: I reached out to CAS for help. Then my daughter died in a fire

The Ministry of Children and Youth Services, responsible for licensing and inspecting these homes, is under fire for failing to adequately monitor and for being slow to improve the quality of care.

Both group homes and foster homes serve children and youth taken for their protection from parents by children’s aid societies, or sent there by parents for treatment due to mental health or behavioural issues.

The similarities end there. Foster homes are capped at four children, while group homes typically serve eight or more. Foster homes also face far less stringent licensing requirements and fire code regulations.

Confusion around the bolted windows commonly used in these homes is especially striking.

A week after the tragedy, a second Connor foster home for boys on the same Quaker Rd. property was shut down by the Kawartha Lakes fire department for more than a dozen violations of the Ontario Fire Code. It demands changes “required to reduce the threat to life for the children to re-occupy the building.”

“Windows throughout the building have been altered such that they cannot be operated as intended from the inside without the use of tools,” the order says, describing a deficiency. “The windows have been altered with the placement of plexi-glass.”

“Windows are to be repaired to operate as originally designed or are to be replaced,” it adds.

But Connor, head of Connor Homes and president of the Ontario Association of Residences Treating Youth, appealed the shutdown order — and won. The fire department withdrew the order March 30 because it had wrongly inspected the building as a group home when in fact it was a foster home, says Kawartha Lakes fire prevention inspector Karl Gleason.

And so, bolted windows considered too dangerous for children in a group home are fine for children in a foster home.

More inexplicable is that during an inspection a year ago, the same fire department gave the same building with the same bolted windows the all-clear when it was operating as a group home. Kawartha fire officials cited the criminal investigation as the reason it could not explain to the Star why they did so.

The bottom line is the fire code is silent about bolted windows in group and foster homes, says Ontario’s child advocate, Irwin Elman.

He considers them a dangerous symbol of the “power and control model” of residential care. “It’s about managing kids’ behaviour,” he says. Elman adds he has repeatedly warned the ministry and fire marshal about them, with no result.

“It wasn’t safe,” an exasperated Elman says of the foster home that burned down. “For young people, it just all adds up to, ‘Nobody cares, unless we die.’”

Today, the Quaker Rd. property is deserted.

Every trace of the wooden building that burned is gone, removed after the insurance company concluded there was nothing to salvage. The two-storey brick home used to foster boys is vacant. A former school portable, its windows bolted shut with Plexiglas, sits at the back of the property. A swimming pool is empty but for dirt. A fridge someone dragged outside has scribbled on its door: “Sorry for the mess. I did my best.”

At the property entrance is a memorial, a bouquet of artificial flowers on a fencepost and a piece of fuchsia fabric with words for Andrea Reid: “Forever our hero.”

“She had a nurturing way with the most challenging kids,” says Mark Williams, who owns the property and for years ran group homes there called Hawk Residential Care and Treatment Homes, before leasing them to Connor Homes last fall. Reid, a mother of three, had worked six years for Hawk.

Kassy, the teen who died, was a Crown ward. In a statement to the Star, her mother, Chantal Finbow, describes her as “a bubbly, social little girl who loved to dance and do gymnastics.” But by the time she was 12, “she became more and more violent” and unmanageable at home.

Finbow turned to the Durham children’s aid for help. Kassy “bounced” through different placements until she landed at the foster home last October. The rural setting was a good fit, her mother says.

“We had seen great improvement, and for the first time in a long time, I had hope that she would return home at some point,” says Finbow.

She questions whether the foster home was the right setting for the girl accused of setting the fire.

The 17-year-old, an indigenous girl from northern Ontario, had been sent to Quaker Rd. last spring by her father who used provincial funding for kids with “complex special needs.” Staff “loved her,” says Williams.

At a court appearance in Lindsay, she sat in the prisoner’s box wearing a baggy sweatshirt, blinking heavily. No relatives were present but a youth worker with an aboriginal family services agency monitored proceedings.

On Feb. 24, the day of the fire, she was one of three girls in the care of the foster home, including Kassy and another girl, who was placed there by Kawartha CAS but away that day with a caregiver.

According to police reports and sources with knowledge of the events, the fire broke out after a disturbance involving the 17-year-old. The two caregivers took Kassy to her second-floor bedroom and waited for the 17-year-old to calm down, part of a pre-arranged plan to keep everyone safe and avoid having to restrain the older teen.

“We were following the protocol, which is laid out by a psychiatrist,” says Connor, 68.

Jennifer Wilson, executive director of the Kawartha Haliburton CAS, questions the plan’s wisdom. “I would be concerned about a safety plan where a child or young person is left alone when in crisis,” Wilson says. “How does that child recover from the episode without coaching or staff support?”

Connor refused to say how the tragedy unfolded. But a source suggested that when smoke alarms connected throughout the house rang, the caregivers in the upstairs room assumed the 17-year-old had pulled the fire alarm as a prank.

The bedroom had been retrofitted with thick drywall and a fire door which would have kept the caregivers and Kassy safe from fire for 20 minutes, the source says.

Firefighters arrived six minutes after they were called, but by then it was too late, the source adds.

Kassy died that day. Reid died in hospital that weekend.

“Smoke is what killed them,” says Connor, adding the fire plan for the home included evacuating the premises at the first sign of fire.

The sliding glass door in Kassy’s bedroom was bolted, he says, because there was no balcony. Connor says bolted Plexiglas windows are common in group homes. They prevent self-harming kids from smashing them or jumping to their deaths.

“There’s no rule in the fire code that says you can’t have the windows bolted shut,” he says. “Common sense would say it’s not a good idea, but the law says it’s fine. Do I think it’s fine? No.”

Williams says that during the years he ran the group home, ministry inspectors never questioned his bolted windows or use of Plexiglas.

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Williams, Hawk’s longtime director of residential services, took over the operating licences for Quaker Rd. in 2011. He bought the homes from Hawk’s previous owners in May 2016 for $485,000 and took out two mortgages, at high interest rates, according to property records.

Over the last two years,the homes became known for a high number of serious incidents reported to the ministry, with many resulting in kids being physically restrained.

A former worker at the boys’ home, who did not want to be named, says he witnessed “a violent outburst every day.” He recalls being choked unconscious by one boy. Staff were paid $13 to $15 an hour, and rarely stayed long. He now works at a jail.

“I feel I’m in a safer job now.”

In July 2016, children’s aid societies removed all their children from the boys’ home after Kawartha CAS investigated a sex assault allegation.

The ministry says it began reviewing Hawk’s group home licences in June. By September, Hawk had “surrendered” its licences, ministry spokesperson Rob McMahon said. Williams told the Star he closed the business due to financing problems.

That month, Williams leased the Quaker Rd. properties to Connor, whose OARTY group represents companies that run group homes and foster homes. Williams is past president of the association.

Connor turned the group homes into foster homes. He made no changes to the buildings and kept some staff, including Reid.

The children’s ministry has launched a licensing review of Connor Homes.

“I complied with everything,” Connor says, “with every rule there is, and I have higher standards than any of them.”

But even provincial children’s minister, Michael Coteau, says existing standards are not good enough.

“Ontario’s residential services system is in need of substantial reform,” he said in a statement to the Star, adding “this level of change will not occur overnight. The issues are complex and structural and cannot be solved with a quick fix.”

Coteau promises to reveal in the next few weeks a “blueprint for reform,” expected to take years to implement. In the meantime, he says he will step up unannounced inspections of group and foster homes flagged by high numbers of serious incidents reported to the ministry.

An average of 15,625 Ontario children were in foster and group homes in 2014-15. More than half are in what is traditionally considered foster care — a family that takes in one or two foster children.

Between 3,000 and 4,000 are in foster homes run for profit by about 100 companies. And another 3,000 are in for-profit group homes.

Foster homes face less stringent fire codes and licensing requirements, largely because the law has the traditional family-based model in mind. With group home operators increasingly setting up foster homes — with paid staff doing shift work and acting as parents — the distinction has largely disappeared. Yet regulations haven’t changed.

For instance, Connor needs a ministry licence for each of the six group homes he operates across Ontario. Each must be inspected by the ministry and the local fire department as part of their annual licence review.

As of April, Connor also operated 28 foster homes, with 79 beds, the ministry says. They do not need individual licences or yearly fire and ministry inspections. As a licensed foster home operator, Connor can open as many foster homes as he likes. The ministry inspects only a selection every year while reviewing his operating licence.

Considered single-family dwellings, foster homes only need smoke detectors on each floor and carbon monoxide detectors in sleeping areas. More rigorous requirements for group homes include annual fire inspections, fire safety plans, interconnected smoke alarms, fire doors and fire exits from every floor.

The Quaker Rd. foster homes were not inspected by the ministry during the six months Connor ran them, but were inspected annually when Williams ran them as group homes.

Coteau is exploring toughening fire code requirements, and Connor agrees. He favours a common fire code for all homes serving children in care, and annual inspections.

Officials with children’s aid societies insist the problems run deeper than lax fire codes.

Mary Ballantyne, head of the Ontario Association of Children’s Aid Societies (OACAS), questions whether staff were qualified to deal with the special needs of some Quaker Rd. foster kids. There are no minimum education or training requirements for caregivers in group homes or company foster homes.

Williams says the problem is a lack of provincial funding, forcing chronically low pay that creates a revolving door of inexperienced staff. However, he notes both staff involved in the fire had been long-time employees.

“The lowest paid people in the system are expected to care for the highest needs kids with virtually no specialized supports,” he says. “Too often the only time we hear about them is when tragedies happen.”

Wilson of the Kawartha Haliburton CAS adds that the ministry does not include quality-of-care standards when licensing company-run foster homes or group homes. The ministry also doesn’t consult societies when reviewing licences of operators in their area, she says.

Another problem, she says, is that societies are not notified of serious occurrences in homes unless a child in their particular care is involved, making it difficult to get the full picture of a residence.

As a result, the OACAS is collecting information about foster and group homes from societies, including serious occurrence reports and other quality measures, to create a “TripAdvisor” type database for workers to use when placing children.

Over the last three years, an ongoing Star investigation, a child’s advocate probe and a government-appointed panel of experts have detailed massive use of physical restraints in group homes, police arrests, shoddy ministry oversight and a sense of abandonment young people feel in care.

Remarkably, proposed legislation, aimed at transforming the system by putting children at the centre of every decision is still silent on most of the reforms recommended by Elman and the expert panel.

“There is a longstanding culture of complacency that accepts things that we wouldn’t accept for our own children,” says Kiaras Gharabaghi, head of Ryerson University’s School of Child and Youth Care and a member of the expert panel. “The kids are just there, a product being moved.”

Ballantyne condemns “the lack of protocol, consistency and real ability in the system to ensure the safety and wellbeing of children.

“I fear there are other potential tragedies out there.”