Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 12, 2026

Observations: Licensing toured the facility and observed damage to some doors within the facility.

Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care,

Corrective Actions Required: Ensure that there is an agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 29, 2026

Observations: Licensing audited the records of two persons in care, one person in care who had a restraint did not have a written restraint agreement from the parent or representative of the person in care.

Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.

Corrective Actions Required: Ensure that there is an agreement to the use of a restraint given in writing by the medical practitioner responsible for the health of the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 29, 2026

Observations: Licensing audited the records of two persons in care, one person in care who had a restraint did not have an agreement given in writing by the medical practitioner responsible for the health of the person in care.

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required: Ensure that a record is kept for each person in care consent in writing from the person in care or a parent or represenative of the person in care to a call a medical practitioner, nurse practitoner or ambulance in case of accident or willness.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 29, 2026

Observations: Licensing audited the records of two persons in care and one person was missing consent to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.

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: 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 Taken By Licensee:

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

To Be Corrected By: May 29, 2026

Observations: Licensing audited two care plans for persons in care, which were last dated in 2024.