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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: Ensure all staff have evidence to show compliance with the Province's immunization control program.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 3, 2026

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

Description: A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.

Corrective Actions Required: Ensure all staff files contain a performance review record.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 3, 2026

Observations: Licensing audited three staff files. Two staff files did not contain a record of a current performance review. Licensing spoke with the Manager who stated that the performance reviews had been completed but the documents had not been electronically uploaded into the staff files.

Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure that all policies and procedures have been reviewed, and if necessary, revised within the last year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 24, 2026

Observations: Licensing audited the facility policies and procedures. Three policies and procedures had not been reviewed within the last year.

Description: A care plan must include all of the following: an oral health care plan

Corrective Actions Required: Ensure all person in care have an oral health care plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 24, 2026

Observations: Licensing audited two person in care's care plans. Both did contain oral health care plans.