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: Ensure that the performance of each employee is reviewed regularly to ensure that the employee continues to meet the requirements of this regulation.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 13, 2026

Observations: Licensing audited three staff files. All three did not contain a current performance reviews. Licensing spoke to the Licensee who stated that the performance reviews had not been completed.

Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,

Corrective Actions Required: Ensure all staff have a record showing compliance with the Province's immunization control programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 13, 2026

Observations: Licensing audited three staff files. Two staff files did not contain evidence of compliance with the Province's immunization control programs.

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required: Ensure that each person in care is weighted at least once each month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 5, 2026

Observations: Licensing audited two persons in care's records and observed one persons in care's weight was not recorded for the month of November, September, and June 2025.