Bouvette Street
Confidential · Residential Care - Licensing
Inspection summary
Bouvette Street has been inspected 8 times by Interior Health Authority since September 22, 2015. The most recent inspection, on April 10, 2026, recorded 2 infractions.
None of the 8 inspections on record were free of infractions. In the past 12 months there was 1 inspection with 2 infractions recorded. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.
The number of infractions per inspection has stayed roughly the same over time.
What these findings mean
Health authorities word their findings differently, so we group them by what they mean for the people in care. Higher-risk findings are the ones that could directly make someone sick, and they matter more here because young children, older adults and people who are unwell are more vulnerable to infection.
Permits, records and postingLower risk
Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.
Recorded 9 times across 5 separate inspections, most recently on December 19, 2023. For example:
6 - Are facility records current and complete?
Equipment and utensilsLower risk
Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.
Recorded once on December 19, 2023. For example:
1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
Other findingsLower risk
Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.
Recorded 12 times across 8 separate inspections, most recently on April 10, 2026. For example:
2 - Is the environment maintained to prevent falls?
About this data
These results come from Interior Health Authority, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.
8 inspections
- Routine Inspection
2 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): It is observed that paver stones are stored in piles in the backyard adjacent to an unfinished yard surface. The patio ramp leads directly into this area, presenting a potential risk for trips or falls and making it potentially difficult for persons in wheelchairs to access this section of the backyard. Submit to Licensing by May 05, 2026, a plan outlining how this area will be remedied to ensure safe and accessible access. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance with legislative requirements.
- R7.2A - Ensure that persons in care who require mobility aids can access all areas intended for use by persons in care; 14 ( 1 )
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): It is noted that some meals do not include at least 3 food groups as described in Canada's Food Guide. Meals that do not include at least 3 food groups may increase the risk of nutrient deficiencies among persons in care. Submit to Licensing by May 05, 2026, a plan outlining how all meals will include at least 3 food groups. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance with legislative requirements.
- R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
- R7.2 - Is the environment maintained to prevent falls?
- Routine Inspection
1 infraction
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): The Licensee does not have a system in place to ensure food is safely stored in the refrigerator after being prepared. During the inspection, it was noted that prepared food in the refrigerator is dated; however, employees are not aware of how long prepared food is allowed to be kept or served and there is no system to ensure food may no longer safe to consume is removed.
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Routine Inspection
4 infractions
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): The Licensees system for retaining immunization records of persons in care was found to be ineffective. During the inspection, the manager noted that a system has been put into place to obtain immunization records of persons in care; however, these records were not able to be located during the inspection. This was also noted to be out of compliance at the last routine inspection. Records of tuberculosis screening were located.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R6.2B - Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
- R4.6 - Are facility records current and complete?
- Observation(s): The Licensee does not have a system to record menu substitutions. During the inspection, it was noted that substitutions are not documented when changes are made to the menu.
- R4.6C - Retain food services records of menus and menu substitutions; 87(b)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): During the inspection, it was noted that there is no menu developed for breakfast, lunch or snacks. There is an evening meal menu created and available.
- R5.1B - Develop a menu for persons in care accommodated for greater than 6 weeks, for at least each 4 week period; 62( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The Licensees system to ensure that water accessible to a person in care does not exceed 49 degrees Celsius was found to be ineffective. During the inspection, 2 separate water sources were tested and 1 of the sources was above the allowable temperature of 49 degrees Celsius.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Routine Inspection
4 infractions
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): A record indicating each person in care's immunization status must be kept as per section 49(1) of the RCR and the Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R6.2B - Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): A system of self-monitoring must be implemented to ensure compliance with the Act and Residential Care Regulation (RCR) in accordance with section 61 of the RCR.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A person must not be employed without the licensee/manager obtaining evidence of/or a written statement of immunization status (to the best of their knowledge). See BC Immunization Schedule.
- 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): A record indicating each employee's immunization status must be kept as per section 86(c) of the RCR.
- R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): UNRESOLVED from last two Inspections conducted January 19, 2017 and February 15, 2018 The system for ensuring employees assess and document the effectiveness of PRN medications administered to persons in care on the Medication Administration Record (MAR) is ineffective. LO reviewed the MAR and discussed the findings with the manager. It was identified that employees are not assessing the effectiveness of PRN medications they are administering. There is documentation why the PRN was administered, however there is no documented assessment if it was effective or not. The manager stated he would contact the pharmacist and inquire about an educational in-service for the employees regarding how to assess PRN effectiveness and the importance of documenting.
- 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): 1) There is no system in place to advise persons in care and their representatives prior to admission of all charges, fees, and other services offered. Licensing Officer (LO) inquired how persons in care and their representatives are informed prior to admission of all charges, fees, and other services offered. 2) There is no system in place to ensure persons in care and their representatives are advised prior to admission of how to express concerns or make complaints to Licensing. LO discussed this with the manager in reviewing the complaint policy and it was noted the policy directs individuals to bring concerns forward to CLBC, and it does not address how to bring concerns forward to Licensing. 3) There is no system in place to communicate the required information in a manner appropriate to the abilities of the person and their representative. The manager provided a copy of the orientation check list to illustrate the topics that are covered when the person is orientated to the facility, however it is only communicated verbally at time of admission.
- R2.1A - Advise of all charges/fees/other payments for accommodation/other services offered prior to admission; 48( 1 )(a)
- R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
- R2.1E - Communicate required advice in a manner appropriate to the skills and abilities of the person, their parent, or representative; 48 ( 2 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): The system in place to ensure that all medications administered to persons in care are labelled by the pharmacy is ineffective. LO inspected the medication cupboard and located bottles of vitamins that were ordered for persons in care, however they did not contain a label from the pharmacy.
- R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): UNRESOLVED - There is no system in place to ensure that employees record the effectiveness of the PRN treatments and medications that they administer to persons in care. LO reviewed persons in care's medication records and observed that the employees continue to not document the effectiveness of the medications and treatments that they give to the persons in care.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): UNRESOLVED - The facility does not have a system in place for the screening of persons in care to determine if they have complied with the province's immunization program. The manager reviewed persons in care's charts online and he was unable to locate immunization screening results.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 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 facility does not have a policy in place to guide the employees in outbreak prevention or outbreak control.
- 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): January 19, 2017 - The facility's system for ensuring compliance with documenting the effectiveness of PRNs administered is ineffective. LO reviewed the medication records for persons in care and observed the employees are not documenting the effectiveness of PRNs administered.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): January 19, 2017 - UNRESOLVED - The facility's system for ensuring compliance with keeping clear and up to date records for the immunization status of each person in care is ineffective. Persons in care's charts do not contain their up to date immunization status. The facility does not have a process in place for ensuring compliance with providing education to the persons in care and/or their representatives in regards to the benefits of immunization.
- R6.2B - Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
- R6.2C - Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): January 19, 2017 - The facility's system for ensuring compliance with obtaining written consent to contact a doctor or ambulance in case of an accident or illness is ineffective. LO reviewed persons in care's charts. LO located signed consent for sharing of information with a physician, however there is no written consent to contact an ambulance if required. The facility's system for ensuring compliance with obtaining and documenting each person in care's monthly weight is ineffective. LO reviewed persons in care's charts and found one person in care's weight to not be documented for two months in a row.
- R4.1I - Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
- R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
2 infractions
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): Unable to locate immunization records on multiple persons in file.
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Hand towels present in multi-person bathroom, not labelled/separated.
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?