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: between January 16 and 22, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: an updated policy related to elopement would be implemented, in January 2026, all employees would be educated on this policy and a new WanderGuard alert task was created in Point of Care (PoC) for monitoring persons in care hourly as per policy. 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: March 11, 2026

Observations: Regarding intake November 11, 2025. Through the investigation process, Licensing determined that the elopement policy was not implemented by employees.

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 community care facility is operated in a manner that will promote 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: between January 16 and 22, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: extra batteries would be kept on site to swap WanderGuard bracelets instead of removing them, in the event the bracelet was removed from a person in care, the employees would be notified and changes to the care plan would be updated. 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: March 11, 2026

Observations: Regarding intake November 11, 2025. Through the investigation process, Licensing determined that a person in care did not have their health, safety and dignity promoted when their WanderGuard bracelet was removed and they were at risk of elopement.