Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required: Ensure that water accessible to person in care, from any source, is not heated to more than 49 degree Celsius.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 3, 2026

Observations: Licensing tested the water temperature in three person in care's bathroom sinks, which had a reading of 55.5, 53, and 55.9 degree Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. It was indicated by the Manager that he would come on site to rectified the problem by adjusting the water temperature and test the water temperature on this date and the Manager would call the maintenance company to rectified the problem if he was unable to lower the water temperature. Full compliance will not be achieved until this plan is implemented and completed.

Description: A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.

Corrective Actions Required: Ensure each person in care is assessed at admission to determine if the person in care is at the risk of leaving the community care facility without notification of an employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 27, 2026

Observations: Licensing audited three persons in care's records and all three did not have an assessment to determine if the person in care were at risk for going missing/wandering.

Description: A care plan must include all of the following: a recreation and leisure plan

Corrective Actions Required: Ensure all care plans include a recreation and leisure plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 27, 2026

Observations: Licensing audited three persons in care's care plan, and all did not contain a recreation and leisure plan.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for preventing the person in care from falling

Corrective Actions Required: Ensure a person in care who receives a type of care described as long term care or who may be prone to falling, has a fall prevention plan, which must address a plan for preventing the person in care from falling.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 27, 2026

Observations: Licensing audited three persons in care's care plan and all did not contain a fall prevention plan.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care

Corrective Actions Required: Ensure in the care of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, there is a fall prevention plan, which must address a plan for following up on any falls suffered by the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 27, 2026

Observations: Licensing audited three person in care's care plans and all did not contain a plan for following up on any falls suffered by a person in care.

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 to prevent the person in care from leaving

Corrective Actions Required: Ensure if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, there is a plan to prevent the person in care from leaving.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 27, 2026

Observations: Licensing audited three persons in care's care plans, and one person in care who was a elopement risk, did not have a plan to prevent the person in care from leaving.

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 if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, there is a plan if the person in care leaves without notification, to locate the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 27, 2026

Observations: Licensing audited three persons in care's care plans, and one person in care who was a elopement risk, did not have a plan if the person in care left without notification, to locate the person in care.