Routine inspection·February 25, 2026

Citations

11 citations recorded^*CCLD

• 1569.69(b)Type B

  Based on staff record review, the licensee did not comply with the section cited above in 3 out of 3 medications staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.- Medications staff #6, #7, #8 have not had annual medication training. Last training was in 2024.

• 1569.319(a)Type B

  Based on observation, the licensee did not comply with the section cited above, as there is no internet capable device for client use only, which poses a potential health, safety or personal rights risk to persons in care.

• 1569.625(b)(1)Type B

  Based on staff record review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.- There is no evidence of required training for staff #2 and #5, who started working in August 2025.

• 1569.625(b)(2)Type B

  Based on staff record review, the licensee did not comply with the section cited above in 1 out of 5 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.- There is no evidence that Staff #3 has received annual training, including 8 hours of dementia training and 4 hours of training restricted health conditions, postural supports and hospice care.

• 87303(a)Type B

  Maintain facility in clean, safe, sanitary condition

  Based on observation, the licensee did not comply with the section cited above, as wooden hand rail outside of kitchen exit to driveway is broken, which poses a potential health, safety or personal rights risk to persons in care.

• 87309(a)Type A

  Ensure hazardous items are locked and not unattended

  Based on observation, the licensee did not comply with the section cited above, as Ajax cleanser is stored in common bathroom, Comet cleanser stored in bathroom of client #1, and Comet cleanser and liquid Fabuloso stored in bathroom of client #4, accessible to clients, who are present. This poses an immediate health, safety or personal rights risk to persons in care.

• 87355(e)(4)Type A

  Request transfer of criminal record exemption

  Based on staff record review, the licensee did not comply with the section cited above in 1 out of 5 staff files reviewed, which poses an immediate health, safety or personal rights risk to persons in care.- Criminal record clearance for Staff #3 is not associated to this facility, and needs to be transferred.

• 87411(f)Type B

  Health screening and fitness requirements

  Based on staff record review, the licensee did not comply with the section cited above in 3 out of 5 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.- Health screenings are not maintained for staff #2, #3, #5, and TB test result is needed for staff #3, who was employed in 2020.

• 87458(a)Type B

  Obtain baseline medical assessment before resident admission

  Based on client records review, the licensee did not comply with the section cited above in 2 out of 5 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care.Medical assessments for clients #3 and #5 are not signed and identified by a physician.

• 87465(h)(2)Type A

  Store centrally held medications in locked secure place

  Based on observation during facility tour, the licensee did not comply with the section cited above, as Albuterol and Claritin are stored in dresser in room of client #1, which poses an immediate health, safety or personal rights risk to persons in care.

• 87468.2(a)(1)Type A

  Right to personal privacy in daily care

  Based on observation, the licensee did not comply with the section cited above, as 2 staff are observed preparing to eat lunch in bedroom of client #2, which poses an immediate health, safety or personal rights risk to persons in care.