Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,

Corrective Actions Required: Ensure a Food Services Manager is a nutrition manager with membership in the Canadian Society of Nutrition Management.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 5, 2026

Observations: Licensing spoke with the Food Services Manager. The Food Services Manager informed Licensing that he did not have a membership in the Canadian Society of Nutrition Management.

Description: A licensee must keep the following records in respect of each employee: character references

Corrective Actions Required: Ensure that character references are kept for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 5, 2026

Observations: Licensing audited 14 staff files. Five staff files did not contain character references.

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 immunization records are kept for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 5, 2026

Observations: Licensing audited 14 staff files. Eight staff files did not contain immunization records.

Description: A licensee must keep the following records in respect of each employee: a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.

Corrective Actions Required: Ensure all staff files contain current performance review records.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 5, 2026

Observations: Licensing audited 14 staff files. Eight staff files did not contain current performance review records. Licensing spoke with the Manager who stated that the performance reviews had been completed but the reports had not been placed in the staff files.