Fire Safety Plan for Retirement Homes in Ontario: The RHRA Requirements Explained

Retirement homes in Ontario operate under some of the most demanding fire safety requirements in the province. This isn't an accident - the population served is among the most vulnerable in any fire emergency, and the stakes are high.

If you own or manage an RHRA-licensed retirement home, here is exactly what the Ontario Fire Code and the Retirement Homes Act require for your Fire Safety Plan, and what happens when things go wrong.

Why Retirement Homes Are a Special Case

Under the Ontario Building Code and Ontario Fire Code, licensed retirement homes are classified as Group B3 occupancies - care occupancies without treatment. This classification reflects the reality that residents have varying levels of mobility and cognitive function, and many cannot self-evacuate without staff assistance.

This single fact drives most of the additional requirements that apply to retirement homes versus a standard commercial building. The fire safety plan has to account for residents who need help getting out of the building - and there has to be enough trained staff to make that happen.

Reference: OBC O. Reg. 163/24 - Group B3 Care Occupancy classification

The RHRA Licence Requirement

When a retirement home applies for or renews its RHRA licence, the application requires submission of a copy of the home's most recent Fire Safety Plan and proof of approval by the local fire department. This is a hard requirement - you cannot obtain or maintain an RHRA licence without a current, approved FSP.

The RHRA also has the authority to flag fire safety issues to the local fire department and the Office of the Fire Marshal. If your FSP is expired or your fire safety practices are found lacking during an RHRA inspection, expect a referral.

Reference: Retirement Homes Act, 2010 - Fire Safety Plan submission requirement

OFC Requirements Specific to Group B3 Occupancies

Fire Drills - Three Times Per Year

Standard commercial buildings are required to conduct fire drills annually. Retirement homes must conduct fire drills a minimum of three times per year, at varied times, to ensure all shifts are covered. Records of every drill - date, time, shift covered, findings, evacuation time, and corrective actions - must be kept on site for a minimum of two years.

Reference: OFC 2.8.3.4 - Fire drill frequency for care occupancies

Sufficient Supervisory Staff

The Ontario Fire Code requires that care occupancy buildings have sufficient supervisory staff to carry out the duties outlined in the Fire Safety Plan. For retirement homes this means that on every shift - including nights and weekends - there must be enough trained staff to evacuate residents who cannot self-evacuate. The local fire department, not the RHRA, determines whether staffing levels are adequate for the fire safety plan.

Reference: OFC 2.8.2.1 - Supervisory staff requirements

Personal Emergency Evacuation Plans (PEEPs)

Every resident who cannot self-evacuate independently during a fire emergency must have a Personal Emergency Evacuation Plan (PEEP) on file. The PEEP documents who the resident is, what assistance they need, who is responsible for assisting them, and where they will be relocated during an emergency. PEEPs are part of the FSP and must be reviewed regularly - at least annually, and whenever there is a change in a resident's condition.

Sprinkler Requirements

As of January 1, 2019, all RHRA-licensed retirement homes are required to be equipped with automatic sprinkler systems meeting NFPA 13. This requirement applies to all homes regardless of when they were built. If your home was grandfathered under an older standard, the compliance deadline has long since passed. Your FSP must document your sprinkler system coverage and maintenance schedule.

Reference: RHRA Public Advisory - Sprinkler requirement effective January 1, 2019

Staff Training Records

Training records must be kept on site and available for inspection by both the local fire department and the RHRA. This means documented evidence that all supervisory staff have been trained on FSP contents, their specific emergency roles, and fire extinguisher use. Frequency: annually and whenever a new staff member is hired or a staff member changes roles.

Reference: OFC 2.8.2.1(h) - Staff training requirements

What a Retirement Home FSP Must Cover

• Emergency procedures specific to a care occupancy - staged evacuation, defend-in-place protocols

• Identification and documentation of all residents requiring assistance

• Individual PEEPs for mobility-impaired residents

• Staff roles and assignments for every shift - not just daytime

• Fire drill schedule and blank drill records

• Sprinkler system documentation including maintenance schedule

• Fire alarm system documentation and two-stage alarm procedures

• Kitchen suppression system documentation if food service is provided

• Annual review and amendment record

What Happens During a Fire Department Inspection of a Retirement Home

When a fire prevention officer inspects an RHRA-licensed retirement home, they go through the FSP in detail. They will typically ask to speak with the person responsible for the plan, review drill records, check staff training documentation, inspect fire protection systems, and confirm that the plan reflects the current state of the building and its residents.

A missing or outdated FSP, missing drill records, or insufficient staffing documentation are all common findings that result in a Notice of Violation. In a retirement home context, the fire department takes these violations seriously - and the RHRA will be notified.

Sterling Safety and Retirement Homes

We specialize in RHRA-licensed retirement homes. We know the specific requirements, we know what Toronto and GTA fire departments expect to see, and we know how to write a plan that gets approved and actually works in practice. Call us for a free consultation.

Sterling Safety — 613-794-3320 | info@sterlingsafety.ca | sterlingsafety.ca  |  Toronto, GTA & Southern Ontario — Free site visit, fixed pricing, fire department submission included.