Axis House Williams Lake

1700 Renner Rd Williams Lake BC V2G 3B3 · Residential Care - Licensing

9 inspections

1. Routine Inspection Follow-upOct 5, 2026

   0 infractions

2. Routine InspectionMar 26, 2026

   5 infractions

   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): One bathtub/shower currently in use does not have slip resistant material on the bottom. Section 30(b) of the Residential Care Regulation requires this to prevent falls. Licensing must be notified that slip resistant material has been added to the tub in question, no later than April 13, 2026.
     • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
   • R9.2 - Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?
     • Observation(s): A supervising pharmacist has not yet been appointed. As part of the medication safety and advisory committee, a supervising pharmacist must be appointed to perform inspections, review policies and procedures respecting medications, and consult with staff with respect to any medication interactions and other problems related to medication. Section 68(2)(c) of the Residential Care Regulation requires this to mitigate risks to persons in care. Licensing must be notified that a supervising pharmacist has been appointed no later than April 13, 2026.
     • R9.2A - Appoint a supervising pharmacist to consult with employees respecting medication interactions and other problems related to medication; 68( 2 )(c)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): Staff records do not do not currently include status of immunization in accordance with the BC Immunization Schedule. Section 37(1)(e) of the Residential Care Regulation requires that this information be collected and kept on site for review in the event of a communicable disease outbreak. Licensing must be notified that immunization status has been added to all staff records no later than April 13, 2026.
     • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): Person in care records do not currently include status of immunization in accordance with the BC Immunization Schedule. The Residential Care Regulation Section 78(1)(a) requires that this information be collected and kept on site for review in the event of a communicable disease outbreak. Person in care records do not contain a record of monthly weight. It is required by the Residential Care Regulation Section 84 (4)(a)(c) that monthly weight be recorded in order to track any significant changes. Licensing must be notified that monthly weight monitoring and immunization status has been added to all person in care records no later than April 13, 2026.
     • R4.1F - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
     • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
   • R9.1 - Are medications stored, handled, and administered appropriately?
     • Observation(s): A medication safety and advisory committee has not yet been appointed. Section 68(1) of the Residential Care Regulation requires that this committee be appointed to ensure proper medication storage, handling and administration by staff. Licensing must be notified that a medication safety and advisory committee has been appointed no later than April 13, 2026.
     • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
3. Routine Inspection Follow-upSep 8, 2025

   0 infractions

4. Routine InspectionNov 27, 2024

   4 infractions

   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): One bath tub requires new slip resistant material to prevent risk of falling. This contravention was identified during previous inspection. One love seat currently in use was observed to be in a state of disrepair at time of inspection. Material is wearing thin and cracking.
     • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
     • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): The manager name was not posted at the time of inspection. This contravention was identified during the previous inspection. A system of self-monitoring on a regular basis must be implemented. Monitoring must include the physical environment and the care and services provided.
     • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
     • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): The current policy respecting monitoring of persons in care requires an update to include the use of video surveillance.
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Written notice of video surveillance must be posted in a prominent place in the facility.
     • R7.1G - Display a notice in a prominent place if electronic surveillance is being used to transmit or record images of persons in care or members of the public; 19 ( 3 )
5. Routine InspectionMay 11, 2023

   3 infractions

   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): One bath tub requires new slip resistant material to prevent risk of falling.
     • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): Manager's name and most recent routine inspection were not posted in a prominent place at time of inspection. Must be in a more noticeable area so that it can be seen by all persons in care.
     • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
     • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): A policy/procedure is required by RCR 85(2)(a.1) in respect of: (i)the use of electronic surveillance, and (ii)the monitoring of interactions between persons in care and visitors
     • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
6. Routine InspectionMay 5, 2022

   6 infractions

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): During inspection a record of internal/minor incidents was reviewed. One report indicating transport to hospital had not been reported to Licensing as required. Please submit this report to Licensing along with a plan to ensure ongoing compliance. Required by section 77(2)(c) of the RCR.
     • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): Resident Bill of Rights, name of manager and the most recent licensing inspection were not posted at the time of inspection. Please post in a prominent place as required.
     • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
     • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
     • R1.1Y - Display the rights of adult persons in care in a prominent place and in a form acceptable to the minister; Act 7( 1 )(c.1)(i)(ii)
   • RB1.21 - Are rights of persons in care prominently displayed in the facility?
     • Observation(s): Bill of Rights not posted in a prominent place in the facility.
     • RB1.21A - Display prominently the rights of persons in care.
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): There currently is not a system in place to review facility policies and procedures annually as required by Section 85(1)(b) of the Residential Care Regulation (RCR).
     • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): LO Vermeulen spoke with human resources employee responsible for staff records. A statement of immunization status (compliance with BC Immunization Schedule) has not yet been collected for each employee of Axis House. Required by section 37(1)(e) of the RCR.
     • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
   • R4.4 - Are records kept on each employee with the necessary requirements?
     • Observation(s): LO Vermeulen spoke with human resources employee responsible for staff records. A statement of immunization status (compliance with BC Immunization Schedule) has not yet been collected for each employee of Axis House.
     • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
7. Routine InspectionJan 16, 2020

   4 infractions

   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): Resident Bill of Rights and the most recent licensing inspection were not posted at the time of inspection. Please post in a prominent place as required.
     • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
     • R1.1Y - Display the rights of adult persons in care in a prominent place and in a form acceptable to the minister; Act 7( 1 )(c.1)(i)(ii)
   • RB1.21 - Are rights of persons in care prominently displayed in the facility?
     • Observation(s): Resident Bill of Rights was not posted at the time of inspection. Please post in a prominent place as required.
     • RB1.21A - Display prominently the rights of persons in care.
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): Records for persons in care were reviewed during inspection. Immunization status is not presently being recorded as required by RCR 78(1)(a)
     • R4.1C - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Water temperature in lower level washroom exceeded 49 degrees Celsius at time of inspection. Found to be 52 degrees Celsius. Must be adjusted to prevent risk of injury.
     • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
8. Routine InspectionDec 10, 2018

   0 infractions

9. MonitoringSep 12, 2017

   4 infractions

   • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
     • Observation(s): TB tests information not currently in place for all staff. Ensure all current staff who do not have a TB clearance on file receive a test soon and have the results included in their staff files. Staff hiring processes need to include information regarding compliance with the Province's immunization and TB control programs. Include in your response what auditing systems are in place to ensure staff have all required documentation in place.
     • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): The current emergency evacuation plan does not include specifics regarding where staff/PIC's would evacuate to if they were not able to return to the facility in an emergency. Please update the emergency procedures to include a secondary location including specific information on how staff are to transfer PIC's. Ensure staff are trained on the procedures. Please include in your response how often the plan will be reviewed/audited and how all staff are trained on the procedures.
     • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
   • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
     • Observation(s): A menu is currently in place that indicates dinner meal service, the facility indicates PIC's often do not want to eat the food offered so other choices have been made available. Inform Licensing regarding what systems are in place to track the food intake of PIC's and what food is available for PIC's if they do not want to eat the food prepared.
     • R5.1A - Develop a weekly menu for persons in care accommodated for 6 weeks or fewer; 62( 1 )(a)
   • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
     • Observation(s): PIC's are currently involved in some food prep at the facility, inform Licensing on what food safety provisions/audits will put in place in lessen the likelihood of food contamination.
     • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )