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 that the Licensee operates the community care facility in a manner that promotes the health, safety, and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 9, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: On February 25, 2026, staff reviewed relevant policies related to documentation of monitoring persons in care, on March 10, 2026, there was implementation of weekly policy implementation monitoring, by March 31, 2026, there was implementation of a formal competency sign-off checklist related to documentation, behaviour support, and medication and by April 1, 2026, integration of policy adherence and documentation standards were added into the supervision and performance review process. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 24, 2026

Observations: Regarding intake dated December 16, 2025. Through the investigation process, Licensing determined that the Licensee did not operate the community care facility in a manner that promoted the health, safety, and dignity of persons in care. Specifically, staff did not demonstrate the skills necessary to carry out the duties assigned.

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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 9, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: On February 25, 2026, staff reviewed relevant policies related to documentation of monitoring persons in care, on March 10, 2026, there was implementation of weekly policy implementation monitoring and by April 1, 2026, integration of policy adherence and documentation standards were added into the supervision and performance review process. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 24, 2026

Observations: Regarding intake dated December 16, 2025. Through the investigation process, Licensing determined that policies were not implemented by employees.

Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

Corrective Actions Required: Ensure that the Licensee operates the community care facility in a manner that promotes the health, safety, and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 9, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: On February 25, 2026, staff reviewed relevant policies related to documentation of monitoring persons in care, on February 28, 2026, the Manager conducted a 30-day retrospective audit of documentation for persons in care and provided written feedback to staff, on March 5, 2026, all facility staff attended a documentation and regulatory compliance training and were required to pass a competency quiz post-training, by March 31, 2026, there was implementation of a formal competency sign-off checklist related to documentation, behaviour support, and medication, by April 1, 2026, integration of policy adherence and documentation standards were added into the supervision and performance review process, annual documentation refresher training would be implemented, and there would be weekly communication log and persons in care's log audits conducted. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 24, 2026

Observations: Regarding intake dated December 16, 2025. Through the investigation process, Licensing determined that the Licensee did not operate the community care facility in a manner that promoted the health, safety, and dignity of persons in care. Specifically related to documentation.