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 a persons in care, from any source, is not heated to more than 49 degrees Celsius.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 28, 2026

Observations: Licensing audited three person in care bathroom sink water temperatures which all had water temperatures that exceeded 49 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Maintenance Manager was notified and was addressing the hot water temperature prior to Licensing leaving the facility. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: character references in respect of the person

Corrective Actions Required: Ensure that the Licensee does not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained character references in respect of the person.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 30, 2026

Observations: Licensing audited three staff files. Two staff files did not contain two character references. Licensing spoke to the Executive Director who stated that the character references had not been completed.

Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,

Corrective Actions Required: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 30, 2026

Observations: Licensing audited three staff files. Two staff files did not contain a performance review. Licensing spoke with the Executive Director who stated that the performance reviews had not been completed.

Description: A licensee must make a policy respecting all of the following the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises

Corrective Actions Required: Ensure there is a policy respecting the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 30, 2026

Observations: Licensing audited the facility policies and procedures. There was no policy respecting the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises.

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 that each person in care is assessed on admission to determine the risk that the person in care may leave 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: April 30, 2026

Observations: Licensing audited three person in care files. Three person in care did not have an elopement risk assessment. Licensing spoke with the Executive Director who stated that elopement risk assessments were not completed on all persons in care on admission.