Description: Despite subsection (1), a licensee may accommodate 2 persons in care in a bedroom if fewer than 5% of the maximum number of persons in care that the community care facility is licensed to accommodate share a bedroom

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing observed that the exemption for the section RCR 25(2)(a) had expired July 20, 2022. Licensing observed four double bedrooms.

Description: A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.

Corrective Actions Required: Ensure the menu is displayed in a prominent place in the dining room.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 29, 2023

Observations: Licensing observed the menu was not displayed in a prominent place in the dining room.

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: a criminal record check for the person

Corrective Actions Required: Ensure all staff have a criminal record check.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 30, 2023

Observations: Licensing reviewed five staff files and one staff file did not have a copy of a criminal record check.

Description: Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: character references in respect of the person

Corrective Actions Required: Ensure staff have character references in respect of the person.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 15, 2023

Observations: Licensing observed five staff files and four staff files did not have character references in respect of the person.

Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,

Corrective Actions Required: Ensure that the Food Service Manager is a member in the Canadian Society of Nutrition Management.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 29, 2023

Observations: Licensing observed that the current Food Service Manager was not a member in the Canadian Society of Nutrition Management.

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 staff have record of compliance with the Province's immunization and tuberculosis control programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 15, 2023

Observations: Licensing observed five staff files and two staff files did not have record of compliance with the Province's immunization and tuberculosis control programs.

Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care

Corrective Actions Required: Ensure that if a person in care has been determined to be at risk of missing/wandering, they have a care plan that includes a plan to locate the person in care if missing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 15, 2023

Observations: Licensing reviewed five care plans and one person in care, who was determined to be at risk of missing/wandering, did not have a plan that addressed if a person in care left without notification.