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Caramillo Heights

547 Caramillo Ct Kelowna BC V1V 2K9 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Caramillo Heights has been inspected 13 times by Interior Health Authority since July 30, 2015. The most recent inspection, on June 17, 2026, recorded 2 infractions.

1 of 13 inspections on record found no infractions at all. 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.

Recent inspections have recorded fewer infractions than earlier ones, so the record is improving.

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 These findings are administrative: the documentation was missing or out of date at the time of inspection.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 32 times across 10 separate inspections, most recently on August 26, 2024. For example: 5 - Are incidents and notifications reported and records retained as required?

  • 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 6 times across 6 separate inspections, most recently on June 17, 2026. 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 28 times across 11 separate inspections, most recently on June 17, 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.

13 inspections

  1. Routine Inspection

    2 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): A window is not secured to prevent falls or exiting, as it could be opened fully exposing a window screen which could easily be breached. The window not being secured contrary to Residential Care Regulation 15(1) can increase the risk of elopement or a fall through the window. Please submit to Licensing on/before July 7, 2026, a plan outlining how the window will be secured to prevent falls or exits. 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.
      • R7.2C - Windows must be secured to prevent falls from, or exiting through, the window; 15 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Cleaning products are accessible to persons in care through a garage door which could be easily unlocked from inside the residence. Access to hazardous items contrary to Residential Care Regulation 35(1)(c) can increase the risk of ingestion or other misuse by persons in care. Please submit to Licensing on/before July 7, 2026, a plan outlining how cleaning products will be securely and safely stored. 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. A broken floor vent is observed beside a dining table. A broken floor vent, contrary to Residential Care Regulation 22(1)(c) can increase the falls risk for persons in care. Please submit to Licensing on/before July 7, 2026, a plan outlining how the floor vent will be maintained in a safe and clean condition. 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. Stains on the roof are observed above a dining area. As per the Licensee Contact, the stains do not present an immediate risk to persons in care. The stains are contrary to Residential Care Regulation 22(1)(c), as the roof was not maintained in a clean condition. These stains while posing minimal risk, can affect the dignity of persons in care. Please submit to Licensing on/before July 7, 2026, a plan outlining how the roof containing the stains will be maintained in a clean condition. 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. Prominent scratches and dents are observed on a bedroom door and on nearby walls. The scratches and dents are contrary to Residential Care Regulation 22(1)(b), which don't present an immediate risk but can affect the dignity of persons in care. Please submit to Licensing on/before July 7, 2026, a plan outlining how door and subsequent walls in the high traffic area will be maintained in a good state of repair. 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. Person in care's records are not securely stored, as they are stored in an accessible desk cupboard. Contrary to Residential Care Regulation 35(1)(b), this can increase the risk of unauthorized persons accessing records for persons in care. Please submit to Licensing on/before July 7, 2026, a plan outlining how the personal records will be securely and safely stored. 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.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  2. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 22(3) - The Licensee does not have a system in place to ensure ceiling tract lifts are regularly inspected and maintained. The facility Manager advised that ceiling tract lifts are not regularly maintained or inspected and that staff are expected to perform visual safety checks prior to use; however, these checks are not documented. Lack of regular inspection and maintenance increases risk to persons in care as equipment may not be in optimal working condition and may lead to injury of persons in care. A health and safety plan was requested by the Licensing Officer and submitted by the Licensee. The accepted plan includes details on how the Licensee will come into compliance and a system for ongoing monitoring to ensure ceiling tract lifts are maintained and inspected on a regular basis. 35(1)(c) - The Licensee's system to ensure hazardous materials are not accessible to persons in care was found to be ineffective. During the inspection, a bottle of mouthwash containing alcohol was noted to be in a bathroom cabinet and accessible to persons in care. The Manager removed the mouthwash from the cabinet during the inspection. Hazardous materials being accessible to persons in care increases risk as the product may be ingested and cause illness or adverse reactions. Submit by May 15, 2025, a plan outlining how it will be ensured that hazardous materials are not accessible to persons in care. The plan must include the system for ongoing monitoring.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  3. Routine Inspection Follow-up

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Contravention RCR 77(2)(c) - During follow up of a reportable incident it was noted that suspected financial abuse had not been reported to licensing. RCR section 77(1)(a)(ii) states that any alleged or suspected emotional, physical, financial or sexual abuse, or neglect must be reported to licensing. An incident report was requested by licensing and submitted by the licensee.
      • 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)
    • 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): Contravention Residential Care Regulation (RCR) 85(1)(a) - During follow up of a reportable incident it was noted that the facility policy regarding abuse did not guide the staff in appropriate actions to take if abuse is suspected from someone other than an employee, such as a family member, someone at a work, or an outside program. The policy also failed to guide staff on when to notify licensing if abuse is suspected. Contravention RCR 85(1)(d) - During follow up of a reportable incident it was noted that facility policy was not followed regarding admission screening. The facility policy states that Program Coordinators will ensure all Admissions Screening requirements are completed prior to admission. It also advises that admission screening will include Screening Information Sources; however, upon review of a person in care's admission screening document, it was noted that there was no evidence of this screening occurring, as Section F: Screening Information Sources was left blank.
      • 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)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Contravention RCR 50(1) - During follow up of a reportable incident it was noted that there was no system in place to regularly monitor persons in care to ensure they are still capable of making their own decisions. It was determined through correspondence with the Quality Service Coordinator that any assessments would only be completed at the family's request; however, this regular monitoring is a requirement and responsibility of the licensee under the Residential Care Regulation.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  4. Routine Inspection

    3 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee's system to ensure restraint monitoring documents are accurate was found to be ineffective. During the inspection, a restraint monitoring document was reviewed and it was observed that the charting was being done at the end of the shift and not at the time monitoring was occurring.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee's system to ensure that all records are current was found to be inefficient. During the inspection, it was observed that a document contained out of date Licensing information.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The Licensee does not have a system in place to ensure that when a person in care refuses to be weighed that it is recorded in the nutrition plan. During the inspection, three person in care's charts were reviewed, one chart had gaps in monthly weight monitoring with no explanation as to why it was not completed.
      • R10.3S - Record in the nutrition plan the reason why a person in care has refused or is unable to be weighed and that immediate advice is sought of a health care provider when it appears that a person in care may have experienced a significant change in weight; 83( 5 )(a) (b)
  5. Routine Inspection

    4 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The Licensee does not have a system in place to ensure that restraints being used are included in the care plan and being monitored. During the inspection it was noted that bed rails are used as a restraint for fall prevention; however, there was no care plan in place to guide employees in their use.
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee's system to ensure that all menu plans meet the legislative requirements is ineffective. During the inspection it was noted the the licensee did not have a system in place to audit menu plans to ensure that they meet the legislative requirements.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The Licensee's system to ensure that all food is safely prepared, stored, served and handled was found to be ineffective. During the inspection it was noted that one food item was expired and another food item was not in original packaging and did not have an expiry date on it.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The Licensee's system to ensure that care plans meet the requirements of the legislation is inefficient. During the inspection it was observed that a person in care who smokes did not have a care plan in place to help guide care. A second care plan was observed to not have sufficient information to guide staff on how to locate a person in care who leaves the facility independently.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
  6. Routine Inspection

    3 infractions

    • 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): Licensing Officer (LO) discussed the admissions process during the inspection. It was found that prior to admission, the Licensee didn't have a system to advise the person, their parent, or representative on how to express concerns to Licensing. LO observed that there wasn't a specific policy guiding staff on where/if to document the effectiveness of a minor medical treatment.
      • 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)
      • R2.1P - 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Licensing Officer observed a staff file which was missing a copy of a required document.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing Officer (LO) observed six weeks worth of menus. LO observed one breakfast per week that didn't involve three food groups as described in Canada's Food Guide.
      • 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)
  7. Routine Inspection

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): UNRESOLVED from the January 13, 2020 Inspection. There is no system in place to ensure that prior to the administration of a PRN medication or treatment, an assessment is conducted and documented, and that the effectiveness of it is assessed and documented following the administration. The Licensing Officer reviewed Medication Administration Records (MARs) and identified a person in care had treatments provided by employees; however, there was no documented assessment indicating why person in care required the treatment. In addition the effectiveness of the treatment was not documented.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): During the physical inspection the Licensing Officer noted a persons in care's two pieces of furniture in their room to not be in maintained in a good state of repair. A door of a cabinet was off the hinge and the dresser was heavily worn with lots of chipped paint and scratches.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • 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): An updated Emergency Preparedness Manual is in place, with updated evacuation plans posted at each emergency exit. The orientation check list has been updated for all employees and includes orientation to the Residential Care Regulation and the Community Care and Assisted Living Act. There is a procedure in place requiring all employees to complete a knowledge test on the legislation within three months of being hired. However, the orientation policy has not been updated to reflect this change in procedure, as it still reads only managers are required to be orientated to the legislation. Therefore this contravention remains UNRESOLVED,
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): There is no system in place to ensure character references, and food safe certificates are obtained prior to the hiring of employees. There is no system in place to ensure that Criminal Record Check (CRC) forms are submitted to the Ministry prior to their expiry. The Manager identified some employees's First Aid Certificates expired during the pandemic. Those with expired Certificates have since been enrolled in First Aid Courses in October and November. The Manager explained the Health and Safety Plan in place to mitigate risk to persons in care is to ensure an employee with a valid and up-to-date First Aid Certificate is on duty, and with persons in care at all times. This plan was submitted to Licensing and accepted. The Licensing Officer reviewed three employee files and noted two files to be missing a valid and current CRC. Licensing Officer requested an immediate review of all employee files to identify how many employees are missing a current CRC. Eight employee's files were noted to be in non-compliance. The Licensing Officer requested an immediate Health and Safety Plan to be submitted identifying how risk will be mitigated. A plan was submitted and approved by Licensing. The Manager submitted a plan for mitigating risk in regards to employees working with an expired or missing Food Safe Certificate. The plan was accepted by Licensing. The Manager stated that a system will be put into place for ensuring all individuals submit the required documents prior to their formal hiring and orientation at the facility.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1Q - Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
  8. Routine Inspection

    8 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): It was observed that a Person in Care's Medication Administration Record did not have the PRN effectiveness documented.
      • 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 - 15-May-2019 There is no system in place to screen for Tuberculosis control program (TB), as per the 'Centre for Disease Control'. A Person in Care's chart was reviewed and there was no TB screen completed for the individual on admission. The Person in Care's immunization records remain incomplete.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R8.2 - Does the program of activities support individualized care plan requirements?
      • Observation(s): UNRESOLVED - 15-May-2019 Documentation of planned programming, designed to meet the objectives of Persons in Care's; physical, social and recreational needs, was incomplete. Documentation did not indicate if alternative activities were offered, accepted or declined, by the Persons in Care.
      • R8.2A - Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): UNRESOLVED - 15-May-2019 The facility does not have a system in place to ensure the ongoing monitoring of care and supervision provided to Persons In Care. The facility submitted a compliance plan 13-June-2019. However, the training and orientation of the new manager and competence based training and documentation, as outlined on the compliance plan submitted by the Licensee, have not been completed as indicated. 7 contraventions from 15-May-2019 Inspection Report remain unresolved. 5 actions noted on compliance plan submitted 04-Dec-2019 have not been implemented as outlined in the plan provided to Licensing. Licensing was not updated that the compliance plan had not been completed in its entirety.
      • 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): 1) Although facility demonstrated having emergency policies and procedures in place, they did not have a detailed plan of how ongoing care would be provided to Persons in Care in the event of an evacuation. 2) The Policy and Procedure manual was updated, however the Licensee did not update the posted emergency evacuation plan. The posted emergency evacuation plan did not identify location of fire extinguishers, emergency exits nor an identified meeting location. The evacuation location, name and contact number listed in the Emergency Policy and Procedure manual is different then the evacuation plan posted at emergency exits. UNRESOLVED - 15-May-2019 3) Licensee has updated their orientation of new managers and employees to the Act and Regulations Policy, however the update does not meet regulation requirements. As per Licensee's Policy 1.2.1, Orientation to to the Residential Care Regulation, does not include orientation of 'ALL' employees to the Act and Regulation. The Licensee did not implement by their orientation policy as the new manager, effective 23-Sept-2019, was not orientated to the Act and Regulation. Licensing provided education to the new manager on reportable incidents (IR's) on 7-Sept-2019 and again on 22-Nov-2019.
      • R2.1G - Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51( 1 )(b)
      • R2.1H - Update emergency plans if there is any change in the facility; 51 ( 2 )
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R4.6 - Are facility records current and complete?
      • Observation(s): UNRESOLVED - 15-May-2019 There is no process in place to retain records of compliance with family and resident council meetings. The manager stated that the facility hosted a BBQ, however there is no record of who was notified of the meeting, who attended, what was discussed, or any actions taken by the Licensee as a result of the meeting.
      • R4.6H - Retain records of compliance with family and resident council required in section 59; 89( 2 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 1) There is no system in place to monitor the temperature of the water accessible by Persons in Care. During inspection it was noted that the water temperature was above 49 degrees Celsius. UNRESOLVED - 01-Aug-2019 2) Persons in Care are not provided a safe, secure place to store valuable property in their bedroom. This issue was discussed by a fellow Licensing Officer, with the Licensee during the 01-Aug-2019 site inspection. At this time Licensee stated that a 'type of lock box' would be secured for each Person in Care's bedroom. A daily system has been established to monitor drawers and cupboards for safe storage. Weekly audits on the safe storage of sharp items in the kitchen are documented and tracked.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): UNRESOLVED - 15-May-2019 1) Person in Care's, Nutrition Care Plans, do not contain nutritional assessments. 2) Person in Care's care plans do not include planned/scheduled recreational and leisure activities, based on the Persons in Care's; physical, social and recreational needs. 3) While reviewing non-reportable incident reports, it was noted that a Person in Care had experienced a significant change in their behaviour that required staff assessment and intervention. However the behavioural care plan was not updated. The Licensee contracts with an organization for specialized behavioural care planning, and this organization has not yet provided an up-to-date care plan for a Person in Care to reflect the significant change in their behaviour.
      • R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  9. Routine Inspection

    0 infractions

  10. Routine Inspection

    13 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): There is no system in place to screen and offer each person in care Immunizations as per the Province's Immunization and Tuberculosis control program. An immunization form has been initiated since the last inspection, however the only item filled out on the form was the annual influenza vaccine. A person in care's chart was reviewed and there was no TB screen completed for the individual on admission.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): There is no process in place for the maintenance and repairs of furniture and equipment used by persons in care. A person in care has a bed frame requiring repairs, and when LO inquired what the process was to ensure maintenance and repairs occur in a timely manner it was identified that there was no process in place. The facility is owned by BC housing so any repairs to the facility are conducted by BC Housing.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • R8.2 - Does the program of activities support individualized care plan requirements?
      • Observation(s): There is no process in place to document activities that are provided to persons in care to show that they meet the objectives in their care plans. The manager stated that 2 of the persons in care leave the facility 5 days a week to participate in community programming. However there is no documentation of activities that are offered to the individual who remains at the facility during the day or for any activities that occur in the evenings or on weekends. There was a book of listed activities, however there were x's located next to each individual and activity indicating that each person in care did not participate in the scheduled activity. There was no documentation to indicate what was offered instead or how the persons in care's recreation and leisure needs are being met.
      • R8.2A - Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
    • RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): Please see comments in section R8.2
      • RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • RB1.19 - Are rights of adult persons in care displayed in a form and in the manner acceptable to the minister?
      • Observation(s): Please see comments in section R1.1
      • RB1.19A - Display the rights of adult persons in care in a form and manner acceptable to the minister.
    • RB1.21 - Are rights of persons in care prominently displayed in the facility?
      • Observation(s): Please se comments in Section R1.1
      • RB1.21A - Display prominently the rights of persons in care.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): There is no process in place for notifying Licensing of renovations and structural changes. Licensing Officer (LO) attended the site for an inspection and discovered renovations and structural changes were being conducted in the basement. The Licensee did not notify Licensing with the plans for the change, or a health and safety plan prior to starting the structural renovations. The Licensee stated that BC Housing owns the facility and he thought they submitted notification to Licensing as they are in charge of the renovations. There is no process in place for the monitoring of the physical environment and the care and services provided to persons in care. This is apparent by the contraventions listed in this report. There is no process in place to ensure the rights of persons in care are displayed in the facility. The Resident's Bill of rights was not posted in the facility.
      • R1.1B - Submit plans for the change to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(i)
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
      • 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)
    • 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): LO inquired on the facility's process for screening persons in care for admission and the process for admitting persons in care to the facility. LO reviewed the facility's policy and procedure manual and there was no policy to guide employees to screen and admit persons in care to the facility. UNRESOLVED from January 19, 2018 inspection. There is no process in place for ensuring the facility's policy for the orientation of new managers and employees includes orientation to the Residential Care Regulations and the Community Care and Assisted Living Act. LO reviewed an orientation check list that included orientation to the Community Care and Assisted Living Act, however it did not include the Residential Care Regulations.
      • 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)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R4.6 - Are facility records current and complete?
      • Observation(s): UNRESOLVED from the January 19, 2018 inspection. There is no process in place to retain records of compliance with family and resident council meetings. The manager stated that she thought the families and persons in care were given the opportunity to come together last summer for a BBQ and a council meeting, however there is no record of who was notified of the meeting, who attended, what was discussed, or any actions taken by the Licensee as a result of the meeting.
      • R4.6H - Retain records of compliance with family and resident council required in section 59; 89( 2 )(b)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): There is no process in place to ensure that the menu contains 2 nutritious snacks from 2 different food groups each day.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): There is no process in place to monitor the storage of hazardous items. LO located a sharp item in an unsecure utensil drawer, LO inquired if sharp items were required to be secured in the facility, and the manager stated yes they are required to be stored securely. The manager relocated the sharp item to a secure location during the inspection.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): There is no process in place to monitor the medication cupboard to ensure medications are returned to the pharmacy when a person in care no longer resides at the facility. There is no system in place to ensure all medications are provided by the dispensing pharmacy. LO inspected the medication cupboard and located a medication that was not provided by the facility's pharmacy. Upon questioning the manager stated that the person in care no longer resided at the facility. During the inspection the manager removed the medication from the cupboard to send back to 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)
      • R9.1I - Medications must be returned to the dispensing pharmacy if the person in care is no longer taking the medication or if the medication has expired; 72(a)(b)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): There is no process in place to ensure that oral, recreation and nutrition care plans are developed for persons in care.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  11. Monitoring

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): There is no system in place to ensure that reportable incidents are reported immediately to Licensing. LO reviewed with the facility manager The Residential Care Regulation s. 77 for reportable incidents, and Schedule D the definitions of reportable incidents. The manager identified various incidents that have occurred and discussed them with LO. The manager will submit three incident reports to Licensing for the reportable incidents that have occurred, and were not reported to Licensing.
      • 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)
    • RB1.9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): There is no system in place to provide the persons in care, and their representatives the opportunity to participate in a resident/family council.
      • RB1.9A - Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): There is no system in place to provide persons in care and their representatives the opportunity to participate in a resident/family council.
    • 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 policy for the orientation of managers and employees does not include orientation to The Residential Care Regulation and The Assisted Living and Community Care Act.
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There is no system in place to offer the persons in care and their representatives an opportunity to come together at least once a year to form a council or group, and discuss the collective interests of the persons in care.
      • R10.2R - Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(a)
  12. Monitoring

    12 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): January 06, 2017 - The facility does not have a system in place to ensure the policy and procedure for reportable incidents is current and reflects schedule D of the Residential Care Regulations. The incident binder had a printed copy of an out dated schedule D that was missing aggression between persons in care and choking.
      • R2.2F - Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): January 06, 2017- The facility does not have a system in place for ensuring compliance with up to date immunization records for persons in care. The facility offered the influenza vaccine to each person in care this fall, however there is no documentation in their immunization records to indicate that they received or refused the vaccine.
      • 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
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): January 06, 2017 - The facility's system to ensure compliance with having a slip resistant surface in the laundry facilities that are accessible to persons in care is ineffective.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • RB1.9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): January 06, 2017 - The facility does not have a system in place to ensure compliance with providing an opportunity for families and persons in care to establish a council and meet annually. The facility has a member of the organization that meets weekly with each individual to discuss how things are going, however there is no opportunity offered to persons in care and their families to come together to form council and meet.
      • RB1.9A - Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): January 06, 2017 - The facility does not have a system in place to ensure compliance with providing an opportunity for families and persons in care to establish a council and meet annually. The facility has a member of the organization that meets weekly with each individual to discuss how things are going, however there is no opportunity offered to persons in care and their families to come together to form council and meet.
    • 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): January 06, 2017 - The facility does not have a system in place to ensure compliance with providing a policy and procedure for the release of persons in care to authorized individuals who may be incapable of providing safe care. January 06, 2017 - The facility does not have a system in place for the medication safety and advisory committee to review its orientation and training given to new employees for the administration of medications.
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
      • R2.1X - Ensure there are written policies and procedures regarding the release of children, youths and vulnerable adults by authorized persons, including if an authorized person appears to be incapable of providing safe care to the person in care; 85( 2 )(f)(i)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): January 06, 2017 - The facility does not have a system to ensure compliance with having written consent to contact a doctor or an ambulance in case of an accident or illness.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): January 06, 2017 - The facility does not have a system in place to ensure compliance with assisting the persons in care with maintaining health and hygiene. Two persons in care share a washroom and there is no process in place to keep their towels and personal toiletries separate.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): January 06, 2017 - The facility's system to ensure compliance with all rooms being maintained in a good state of repair is ineffective. The facility has recently completed many renovations, however the persons in care's bedrooms require wall repair and paint.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): January 06, 2017 - The facility's system for ensuring compliance with having all persons in care's medications dispensed by the facility's dispensing pharmacy is ineffective. A person in care's medication drawer contained an unlabelled bottle of cough syrup. The facility has standing orders from the physician for the cough syrup, however it was not obtained through the facility's dispensing pharmacy and there was no label on it.
      • R9.1D - Ensure medications, except as authorized by the medication safety and advisory committee, remain in the original labelled container or package provided by the dispensing pharmacy until administered; 69 ( 2 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): January 06, 2017 - The facility does not have a system in place to ensure compliance with providing an opportunity for families and persons in care to establish a council and meet annually. The facility has a member of the organization that meets weekly with each individual to discuss how things are going, however there is no opportunity offered to persons in care and their families to come together to form council and meet.
      • R10.2R - Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(a)
      • R10.2S - Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): January 06, 2017 - The facility does not have a system in place to ensure compliance with conducting a nutritional assessment and creating a nutritional care plan for each person in care. Persons in care do not have nutritional assessments or nutritional care plans in their charts. The facility does not have a system in place to ensure compliance with monitoring and updating oral care plans at least once a year. Oral care plans are in place, however they were not documented as being reviewed or updated since 2013.
      • R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
      • R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
  13. Monitoring

    8 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Personal dresser in person in care bedroom is broken, multiple drawer fronts have fallen off, several drawers unusable- ONGOING ISSUE- broken furniture
      • Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Site has a new manager but had not yet reported same to licensing.
      • Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • 2.1 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): Emergency fan-out list for evacuations is out of date. Unable to locate written policy regarding complaint process.
      • Update emergency plans if there is any change in the facility; 51 ( 2 )
      • Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
    • 4.6 Are facility records current and complete?
      • Observation(s): Site does not have or maintain a complaint log.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snacks do not meet the legislated requirements.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Nail clippers and nail files stored for communal use, no established sterilization program. No temperature log for food fridge in kitchen. Food items undated in fridge. Salt in cupboard open/uncovered in bowl.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Soiled areas noted throughout the home: dirt and debris inside kitchen cupboards/drawers, multiple person in care bathrooms dirty, carpets in bedrooms heavily soiled/stained. Additional hazards noted: knives/blades unlocked, accessible stovetop not locked/disabled, gas fireplace with open flame/no cover, old/rusted barbeque in yard, damaged/deteriorating picnic table in yard appears unsafe for weight bearing, unlocked cleaning product. ONGOING ISSUE- carpet cleaning
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Persons in care leaving the facility do not routinely carry identification.
      • Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )

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