A fatality inquiry into the death of a woman in a fire at her group home is recommending the province license all social care facilities and that proper inspections be carried out before those licenses are issued.

Marilyn Lane, 43, had Down syndrome. She was living in the basement suite of the group home in east Edmonton in April 2007.

When the fire broke out, the manager of the home shouted for residents to get out. Lane was found sitting on the bed in her room. However, the smoke and heat were too intense for anyone to get in and retrieve her.

The inquiry heard Lane did not respond to calls to leave the suite through the door nor through the window. Three other residents of the home were able to escape.

The manager testified during the inquiry that Lane had participated in fire drills and successfully got through the window by climbing onto a futon.

But fire investigators concluded that exposed wood framing in the basement heightened the intensity of the fire and the speed at which it spread.

The group home's operator, Independent Counselling Services or ICE, applied for a group home license in August 1995, the inquiry report says.

After a number of reviews and delays, Alberta Family and Social Services decided in February 1999 that the facility didn't need a license.

"The reason given was that their group homes had only four residents who contracted care services from ICE 'while renting the house from another source'," Provincial Court Judge Harry A. Bridges said in his report, released Thursday.

Licensing needs to take place regardless of the number of residents at a group home, Bridges said, and all necessary fire and safety inspections must take place before that licence is issued.

He said while the province wants to limit its involvement to the provision of these types of services, the province take responsiblity for the inspections.

"The difficulty is that the safety of persons under care is fundamental to proper care," he writes. "This can only be ensured by inspections."

Bridges also recommended that if a window is the escape route out of a basement suite, inspectors should make sure there is a sturdy table or ladder underneath.

The Alberta government received the report Thursday and is considering the recommendations.

In July 2007, an Edmonton judge fined ICE $3,450 and the house owners $1,800 for failing to comply with safety standards under the Public Health Act.

Investigators determined the fire was caused by an open flame in the basement of the house.