Capital Care Adult Duplexes

1. April 22, 2026 · Inspection

   Non-compliant

   • Act and Regulation Requirements — REG- Current fire inspection report

     Evidence required of the most recent fire inspection report.

     Issued April 22, 2026. Fix by May 22, 2026. Status: Issued (April 22, 2026).

   • Continuation of Services — Contingency plans

     Evidence required that the continuation of services plan includes provisions for loss of utilities,

     Issued April 22, 2026. Fix by May 25, 2026. Status: Rectified (April 22, 2026).

2. January 14, 2026 · CCHSS Inspection

   Non-compliant

   • Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.

     Issued January 14, 2026. Fix by April 8, 2026. Status: Rectified (January 14, 2026).

   • Infection Prevention and Control — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.

     Issued January 14, 2026. Fix by April 8, 2026. Status: Rectified (January 14, 2026).

   • Act and Regulation Requirements — Requirements for staffing plan are met at all times

     Issued January 14, 2026. Fix by April 8, 2026. Status: Rectified (January 14, 2026).

   • Health Care Providers — Active registration is verified and documented for Regulated Health Care Professionals.

     Issued January 14, 2026. Fix by April 8, 2026. Status: Rectified (January 14, 2026).

   • Medication Management — Policies and procedures in Medication Management are documented and implemented.

     Issued January 14, 2026. Fix by April 8, 2026. Status: Rectified (January 14, 2026).

   • Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Policies and procedures to provide Clients the opportunity for bathing at a minimum of twice a week.

     Issued January 14, 2026. Fix by April 8, 2026. Status: Rectified (January 14, 2026).

   • Safe Bath and Shower Water Temperature — Policies and procedures regarding safe water temperatures are documented and implemented.

     Issued January 14, 2026. Fix by April 8, 2026. Status: Rectified (January 14, 2026).

3. February 8, 2023 · CCHSS Audit

   Non-compliant

   • Medication Management — Policies and procedures in Medication Management are documented and implemented.

     Issued April 30, 2019. Fix by November 30, 2023. Status: Rectified (February 10, 2023).

   • Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is created and reviewed by an Interdisciplinary Team conference.

     Issued February 8, 2023. Fix by May 3, 2023. Status: Rectified (June 5, 2023).

   • Restraint Management — Policies and procedures for Secure Spaces are documented and implemented.

     Issued February 8, 2023. Fix by May 3, 2023. Status: Rectified (September 14, 2023).

   • Restraint Management — Restraint use is reviewed by the Interdisciplinary Team.

     Operator must ensure that when a restraint is used, it is reviewed by the Interdisciplinary Team on

     Issued February 8, 2023. Fix by May 3, 2023. Status: Rectified (September 14, 2023).

   • Medication Management — Policies and procedures in Medication Management are documented and implemented.

     Issued February 8, 2023. Fix by May 3, 2023. Status: Rectified (June 5, 2023).

   • Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.

     Issued February 8, 2023. Fix by May 3, 2023. Status: Rectified (September 14, 2023).

4. February 8, 2023 · Inspection

   Non-compliant

   • Continuation of Services — Practicability, communication and review of plans

     Evidence required that the continuation of services plan is communicated and made available to resid

     Issued February 8, 2023. Fix by December 31, 2023. Status: Rectified (February 9, 2023).

   • Cleaning Requirements — Clean and comfortable environment

     Evidence required of a clean and comfortable environment.

     Issued February 8, 2023. Fix by December 31, 2023. Status: Rectified (February 9, 2023).

   • Maintenance Requirements — Accommodation is maintained

     Evidence required that the accommodation, equipment and furnishings are well maintained and in good

     Issued February 8, 2023. Fix by December 31, 2023. Status: Rectified (February 9, 2023).

5. November 15, 2022 · Inspection

   Compliant

6. January 26, 2021 · Quality Monitoring Visit

   Compliant

7. October 27, 2020 · CMOH Inspection

   Compliant

8. October 7, 2020 · Quality Monitoring Visit

   Compliant

9. July 10, 2020 · Quality Monitoring Visit

   Compliant

10. June 30, 2020 · Quality Monitoring Visit

    Compliant

11. March 30, 2020 · Consultation

    Not assessed (consultation)

12. November 7, 2019 · Inspection

    Compliant

13. November 7, 2019 · Inspection

    Non-compliant

    • Water Temperature — Safe water temperatures

      Evidence required that the hottest water temperature flowing out of the faucets in resident areas do

      Issued November 7, 2019. Fix by April 30, 2020. Status: Rectified (March 25, 2020).

    • Information Respecting the Supportive Living Accommodation — Accommodation information provision

      Evidence required that the information is made available regarding:

      Issued November 7, 2019. Fix by January 31, 2020. Status: Rectified (December 5, 2019).

14. April 30, 2019 · CCHSS Audit

    Non-compliant

    • Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 10, 2023).

    • Medication Management — Policies and procedures in Medication Management are documented and implemented.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 10, 2023).

    • Palliative and End-Of-Life Care — Documented policies and procedures for Palliative and End-of-Life Care.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Quality Improvement and Reporting — Policies and procedures for reportable incidents are documented and implemented.

      An operator must establish, implement and maintain documented policies and procedures for the preven

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 10, 2023).

    • Quality Improvement and Reporting — Policies and procedures for tracking incidents and near-misses are documented and implemented.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 10, 2023).

    • Restraint Management — Documentation for restraint use.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Restraint Management — Policies and procedures for Secure Spaces are documented and implemented.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (July 3, 2020).

    • Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 25, 2020).

    • Restraint Management — Restraint use is reviewed by the Interdisciplinary Team.

      Operator must ensure that when a restraint is used, it is reviewed by the Interdisciplinary Team on

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Restraint Management — Secure Space usage is documented and reviewed by the Interdisciplinary Team.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Restraint Management — Secure Space usage is documented in Client's chart and Care Plan.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Staff Training — Documented compliance to training.

      An operator must document compliance with the requirements in 9.1, 9.2, and 9.3.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 10, 2023).

    • Staff Training — Policies and procedures for Staff training are documented and implemented.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 10, 2023).

    • Standardized Assessment and Person-Centred Care Planning — An appropriate assessment tool for Client's Health Care needs is used.

      An operator must ensure that a client's health care needs are assessed using the appropriate InterRA

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is created and reviewed by an Interdisciplinary Team conference.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (December 12, 2019).

    • Standardized Assessment and Person-Centred Care Planning — The care plan reflects the findings of the assessment and is kept up to date.

      Issued April 30, 2019. Fix by July 30, 2019. Status: Rectified (February 10, 2023).

15. November 2, 2018 · Inspection

    Non-compliant

    • Establishment of a Resident and Family Council — Meeting Every 6 Months to Inform Residents

      Provide evidence that a meeting has been convened to inform residents, their families and persons of

      Issued November 2, 2018. Fix by January 31, 2019. Status: Rectified (January 25, 2019).

16. November 2, 2018 · Inspection

    Compliant

17. November 6, 2017 · Inspection

    Non-compliant

    • Trust Accounts — Trust account records

      Evidence required that trust account records are made available to residents/their representatives.

      Issued November 6, 2017. Fix by April 30, 2018. Status: Rectified (March 28, 2018).

    • Trust Accounts — Opening and maintaining trust accounts

      Evidence required that trust accounts are maintained and receipts are kept for each transaction.

      Issued November 6, 2017. Fix by April 30, 2018. Status: Rectified (March 28, 2018).

    • Social or Leisure Activities — Resident needs, feedback and opinions considered

      Evidence required that residents' opinions have been considered in the planning of social or leisure

      Issued November 6, 2017. Fix by June 30, 2018. Status: Rectified (June 4, 2018).

    • Social or Leisure Activities — Communication of activities

      Evidence required showing how information on social and leisure activities is communicated to reside

      Issued November 6, 2017. Fix by March 31, 2018. Status: Rectified (February 26, 2018).

18. November 7, 2016 · Inspection

    Non-compliant

    • Information Respecting the Supportive Living Accommodation — Terms of residential services agreement

      Evidence required that residential service agreements include the services provided, rates charged,

      Issued November 7, 2016. Fix by March 31, 2017. Status: Rectified (March 9, 2017).

19. November 9, 2015 · Inspection

    Compliant

20. November 19, 2014 · Inspection

    Non-compliant

    • Menu Requirements — Record of meals served

      Evidence required of meals served and substitutions made.

      Issued November 19, 2014. Fix by April 30, 2015. Status: Rectified (April 10, 2015).

    • Information Respecting the Supportive Living Accommodation — Accommodation information provision

      Evidence required that the information is made available regarding:

      Issued November 19, 2014. Fix by February 28, 2015. Status: Rectified (January 30, 2015).

21. November 21, 2013 · Inspection

    Non-compliant

    • Menu Requirements — Record of meals served

      Evidence required of meals served and substitutions made.

      Issued November 21, 2013. Fix by March 31, 2014. Status: Rectified (February 28, 2014).

• How does the home meet: Act and Regulation Requirements — REG- Current fire inspection report?
• How does the home meet: Continuation of Services — Contingency plans?
• How does the home meet: Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.?
• How does the home meet: Infection Prevention and Control — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.?
• How does the home meet: Act and Regulation Requirements — Requirements for staffing plan are met at all times?
• How does the home meet: Health Care Providers — Active registration is verified and documented for Regulated Health Care Professionals.?

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