Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: character references in respect of the person

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two staff files. Two staff files contained two character references.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two staff files. Two staff files contained a current performance review.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A licensee must make a policy respecting all of the following the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the facility policies and procedures. There was a policy related to the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.

Corrective Actions Required: Ensure that each person in care is assessed on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: April 30, 2026

Observations: Licensing audited three person in care files. Three person in care did not have an elopement risk assessment. Licensing spoke with the Executive Director who stated that elopement risk assessments were not completed on all persons in care on admission.