Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing toured the facility and observed that the premise appeared to be kept in a good state of repair. Licensing also observed the new carpet runners on the staircases.

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

To Be Corrected By:

Observations:

Description: A licensee must keep the following records in respect of each employee: character references

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited four staff files and records and observed that all staff had two character references kept on file.

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

To Be Corrected By:

Observations:

Description: A licensee must ensure that each menu provides a variety of foods, taking into consideration the texture, colour and matters that affect food safety, taste and visual appeal,

Corrective Actions Required: Ensure that each menu provides a variety of foods, taking into consideration the texture, colour and matters that affect food safety, taste and visual appeal.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 13, 2026

Observations: Licensing audited the menus for the facility and observed that all four of the weekly menus had "toast" for breakfast, and there was not sufficient variety of foods for the meals and snacks each week.

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 weighed at least once each month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 13, 2026

Observations: This contravention was carried over from the Routine Inspection dated August 14, 2025. On this date Licensing audited the monthly weights for November and December 2025 and January 2026, and observed that three persons in care were missing weight records for November 2025 and January 2026, and six persons in care were missing weight records for December 2025.

Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Corrective Actions Required: Ensure the community care facility is operated in a manner that will promote the health, safety, and dignity of persons in care; specifically, that the terms and conditions on the licence are followed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 9, 2026

Observations: Related to the terms and conditions on the licence, on today's date, Licensing discussed the conditions on the licence with the Manager. Related to Condition 2: Licensing audited the staff schedule and observed that one nursing professional, other than the Manager, worked for 12 hours per week. The Manager confirmed that they had a Registered Nurse (RN) who worked 12 hours per week on-site, which did not meet the required 20 hours per week on-site, according to the condition. Related to Condition 3: The Manager stated that not all Registered Care Aides (RCAs) who administered medications had completed an additional Medication Assistant Certification training program. In addition, Licensing had not received any information related to courses and was therefore yet to approve any Medication Assistant Certification training program prior to staff enrollment, as per the condition. Related to Condition 5: The Manager stated that there were two persons in care who required diabetic diets who were assessed as needing such prior to their admission. The Manager stated that there had not been any Dietitian or Nutritionist consultations for the two persons in care since their admission. Licensing requested an immediate plan to be submitted to Licensing regarding noncompliance with the conditions on the licence.