Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed staff files. All three staff have a criminal record check that expired in 2031.

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: compliance with the Province’s immunization and tuberculosis control programs,

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing audited staff files for all three staff. All three staff had evidence of compliance with the Province's immunization and tuberculosis control program, in the form of a TB test and Immunization Status form.

Description: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.

Corrective Actions Required: Ensure that is a person in care is admitted to a community care facility for more than 30 days, there is a care plan for the person in care made in accordance with this section within 30 days of admission.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 22, 2026

Observations: Licensing reviewed two person in care's care plans. One person in care, who was admitted to the facility in September 2025, did not have a care plan.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plans of two persons in care and both had care plans reviewed and revised in February 2026.

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

To Be Corrected By:

Observations: