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: Ensure that records in respect to complaince with the Province's immunization and tuberculosis control programs are kept for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: October 9, 2025

Observations: Licensing audited six staff files and records and observed that four of the six staff did not have a record of immunization kept on file.

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: October 31, 2025

Observations: Licensing audited six staff files and observed that two of the six staff did not have an annual performance review on file. Facility policy states that staff were to have their performance reviewed annually.

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 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: October 31, 2025

Observations: Licensing audited the records and care plans for four persons in care and observed that all persons in care did not have a record of immunization kept on file.