Description: A licensee must ensure that each bedroom is directly accessible from a hallway without passing through any other room.

Corrective Actions Required: Ensure that each bedroom is directly accessible from a hallway without passing through any other room.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 28, 2026

Observations: Licensing toured the facility and observed one person in care's bedroom that was accessible from another room.

Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure that policies are implemented by employees.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 15, 2026

Observations: Licensing reviewed the facility's performance review policy, which required annual employee performance evaluations, and audited three staff files. Annual performance evaluations had not been completed for any of the three employee's file audited in accordance with facility policy.

Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: Ensure that all persons admitted to a community care facility to comply 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 8, 2026

Observations: Licensing audited three persons in care's records and all did not contain a record of immunization.