Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 9, 2026

Observations: Licensing tested six persons in care's washroom sinks. All of persons in care's washroom sinks had hot water readings between 50 and 52.4 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Director of Care (DOC) stated that the Maintenance Manager would check the water temperature daily for all units and adjust the boiler temperature control accordingly. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory comittee.

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 the narcotic count sheets and found that, on most occasions, only one staff signature was documented during narcotic counts completed at shift change. The Medication Safety Advisory Committee (MSAC) policies indicate that two staff signatures are required when conducting narcotic counts during shift changes.

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required: Ensure each person in care's record contains a consent in writing from the person in care or parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in care of accident or illness.

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 twenty persons in care files and found that 13 out of 20 files did not contain written consent from the person in care, or from a parent or representative, authorizing staff to contact a medical practitioner, nurse practitioner, or ambulance in the event of an accident or illness.

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required: Ensure each employee has a current criminal record check result.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 29, 2026

Observations: Licensing audited 15 staff files. One staff file contained an expired Criminal Record Check (CRC). The Director of Care (DOC) stated that a new application is in process and the staff will not provide care until a valid CRC is obtained.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

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 four medication rooms and found that three of the four medication rooms each contained one expired medication, dated in 2025.