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Cloverley House - Mental Health

1057 Cloverley St, North Vancouver BC V7L 1N4 · Mental Health

Official record from Vancouver Coastal →

Inspection summary

Cloverley House - Mental Health has been inspected 10 times by Vancouver Coastal Health since April 15, 2021. The most recent inspection, on April 22, 2026, recorded 6 infractions.

1 of 10 inspections on record found no infractions at all. In the past 12 months there was 1 inspection with 6 infractions recorded. The higher-risk findings here relate to: Chemicals and toxic substances.

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 your health. Higher-risk findings are the ones inspectors treat as critical, because they can directly make someone sick.

  • Chemicals and toxic substancesHigher risk

    Cleaning products, disinfectants and pesticides must be labelled and stored safely, away from food and from surfaces people touch. Inspectors flag chemicals that could contaminate food or harm people, as well as pest treatments applied without proper supervision.

    Recorded once on July 23, 2025. For example: There are secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials [RCR Sec 35(1)(c)]

  • 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 These findings are administrative: the documentation was missing or out of date at the time of inspection.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 28 times across 7 separate inspections, most recently on April 22, 2026. For example: The facility has a written policy and procedure for obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility. [RCR Sec 85(2)(m)]

  • Building, plumbing and upkeepLower risk

    Floors, walls and ceilings must be clean and in good repair, with working lighting, ventilation, plumbing, hot and cold water, and washrooms. These are rarely an immediate health risk on their own, but persistent problems can lead to pest or sanitation issues.

    Recorded 8 times across 6 separate inspections, most recently on April 22, 2026. For example: Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]

  • 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 7 times across 6 separate inspections, most recently on April 22, 2026. For example: Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]

  • Food safety training and certificationLower risk

    Many jurisdictions require a trained or certified person on site, such as a certified food handler. These findings mean the training record or the trained person was missing at the time. They do not by themselves mean anything was handled unsafely.

    Recorded 2 times across 2 separate inspections, most recently on April 14, 2022. For example: Employees have experience, competence and training to ensure food is safely prepared, handled and meets the nutritional needs [RCR Sec (44)(1)(a)]

About this data

These results come from Vancouver Coastal Health, 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.

10 inspections

  1. Routine

    6 infractions

    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
    • The facility has a written policy and procedure for obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility. [RCR Sec 85(2)(m)]
    • Care plan(s) is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care or at least once a year [RCR Sec 81(4)(b)]
    • Menu provides a minimum of 2 nutritious snacks; each snack contains a minimum of 2 food groups as per Canada's Food Guide. [RCR Sec 62(2)(b)]
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
    • A qualified employee is designated to organize and supervise physical, social and recreational activities and has sufficient time to carry out activities [RCR Sec (45)(a)(b)]
  2. Routine

    12 infractions

    • Reportable incidents have been reported to the Medical Health Officer in the form and manner required. [RCR Sec 77(2)(c)]
    • The most recent routine inspection record is displayed in a prominent place. [RCR Sec. 11(1) (b), (2); Bill of Rights 4(b)]
    • There is a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan [RCR Sec 55(1)(a); Bill of Rights 2(c)]
    • Care plan(s) is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care or at least once a year [RCR Sec 81(4)(b)]
    • There is evidence of employee(s) continued compliance with the Province's immunization and TB program [RCR Sec 39(1)]
    • All persons admitted comply with the Province's immunization and TB control programs[RCR Sec 49(1); DOLSOP]
    • Furniture and equipment meets the needs, of the persons in care, are compatible with the health safety and dignity, are well maintained, and clean. [RCR Sec 21]
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
    • There are secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials [RCR Sec 35(1)(c)]
    • The written policies and procedures are reviewed and revised if necessary at least once each year [RCR Sec 85(1)(b)]
    • There is a medication administration record showing all medication administered, the date, amount and time the medication was administered to the persons' in care [RCR Sec 78(2)]
    • A qualified employee is designated to organize and supervise physical, social and recreational activities and has sufficient time to carry out activities [RCR Sec (45)(a)(b)]
  3. Routine Follow-up

    2 infractions

    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
      • Rooms and common areas are not maintained in a good state of repair.
    • If used by persons in care, laundry facilities have a slip resistant floor surface [RCR Sec 35(2)(a)]
  4. Routine

    3 infractions

    • All persons admitted comply with the Province's immunization and TB control programs[RCR Sec 49(1); DOLSOP]
      • Non compliance with the Provinces TB control program
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
      • Rooms and common areas are not maintained in a good state of repair.
    • If used by persons in care, laundry facilities have a slip resistant floor surface [RCR Sec 35(2)(a)]
  5. Routine

    0 infractions

  6. Routine

    1 infraction

    • The written policies and procedures are reviewed and revised if necessary at least once each year [RCR Sec 85(1)(b)]
  7. Routine

    12 infractions

    • Prior to and or on admission persons in care are informed of all charges, fees and other amounts that must be paid for accommodation and other services [RCR Sec 48(1) (a); Bill of Rights 4(c)]
    • There is a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan [RCR Sec 55(1)(a); Bill of Rights 2(c)]
    • Persons in care are encouraged to participate in the facility's program of activities and to take advantage of opportunities available in the community [RCR Sec 55(1)(b); Bill of Rights 2(c)]
    • The care plan(s) contains all items that must be recorded under this regulation [RCR Sec 81(3)]
    • The implementation of care plans is monitored on a regular basis to ensure proper implementation [RCR Sec 81(4)(a)]
    • When a manager resigns or is absent for more than 30 consecutive days notification to Community Care Facilities Licensing has been given and there is a replacement [RCR Sec 8(3)]
    • Furniture and equipment meets the needs, of the persons in care, are compatible with the health safety and dignity, are well maintained, and clean. [RCR Sec 21]
    • Bathrooms have conveniently located and securely attached grab bars beside toilet(s), bathtub(s) and shower(s) to meet the needs and preferences of persons in care [RCR Sec. 30(c)]
    • The written policies and procedures are reviewed and revised if necessary at least once each year [RCR Sec 85(1)(b)]
    • All policies and procedures are available to employees, the medical health officer and the person in cares' representative on request [RCR Sec 85(1)(c)( i, ii, iii)]
      • Policies and procedures are not available to employees at all times.
    • Employees have experience, competence and training to ensure food is safely prepared, handled and meets the nutritional needs [RCR Sec (44)(1)(a)]
    • A qualified employee is designated to organize and supervise physical, social and recreational activities and has sufficient time to carry out activities [RCR Sec (45)(a)(b)]
  8. Routine

    2 infractions

    • The facility has a written policy and procedure for obtaining consent, in accordance with Part 3 IC of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility. [RCR Sec 85(2)(m)]
    • All rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis [RCR Sec 22(3)]
  9. Routine

    7 infractions

    • Persons in care are permitted to keep furniture, ornaments or other personal belongings in their room. [RCR Sec 29(2); Bill of Rights 2(f)]
    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
      • Employees have not been trained in the emergency plan.
      • Employees have not been trained in the use of emergency equipment.
    • There is an emergency plan displayed in a prominent place that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for evacuation and how persons in care will be cared for [RCR Sec 51(1),(4)]
      • Emergency plan does not include all required elements.
    • The facility has a written a policy and procedure for obtaining consent, in accordance with Part 3 of the Health Care (Consent) and
    • Care plan(s) is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care or at least once a year [RCR Sec 81(4)(b)]
    • All persons admitted comply with the Province's immunization and TB control programs[RCR Sec 49(1); DOLSOP]
    • All rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis [RCR Sec 22(3)]
  10. Routine

    19 infractions

    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
      • Employees have not been trained in the emergency plan.
      • Employees have not been trained in the use of emergency equipment.
    • Prior to and or on admission persons in care are informed on how to express concerns or make complaints to the medical health officer or the Patient Care Quality Office [RCR Sec 48(1)(c); Bill of Rights 3(e)]
      • Persons in care are not advised on how to express concerns or make complaints to the medical health officer.
      • Persons in care are not advised on how to express concerns or make complaints under the Patient Care Quality Review Board Act.
    • Required advice is communicated in a manner appropriate to the skills and abilities of the person or the person's parent or representative. (RCR Sec 48(2); Bill of Rights 4(e)]
    • The facility has a written a policy and procedure for obtaining consent, in accordance with Part 3 of the Health Care (Consent) and
    • Care plans take into account the persons in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences [RCR Sec 81(2)(b); Bill of Rights 1(b)]
    • A short term care plan is developed on admission to guide staff in protecting and promoting the health and safety of the person in care [RCR Sec 80(1); Bill of Rights 1(a)]
      • Not all required elements are recorded in the short term care plan.
    • Care plans are developed within 30 days of admission for admissions of 30 days or more. [RCR Sec 81(1); Bill of Rights 1(a)]
    • The most recent routine inspection record is displayed in a prominent place. [RCR Sec. 11(1) (b), (2); Bill of Rights 4(b)]
    • Screening is done prior to admission to ensure safe and adequate care [RCR Sec 47(1), (2)]
      • Any criteria set by, or advice or information from, a funding program has not been considered.
      • Design of the facility and/or equipment has not been considered.
    • Persons in care are assisted in daily oral health care and are encouraged to have a dental exam once a year [RCR Sec 54(3)]
      • Yearly dental exams are not encouraged.
    • Person(s) in care has been provided with the appropriate documentation to keep in their possession when away from the facility [RCR Sec 56(1)]
      • The person in care has not been provided with documentation.
    • The care plan(s) contains all items that must be recorded under this regulation [RCR Sec 81(3)]
      • Does not include a nutrition plan that assesses a person in care's nutrition status.
      • Does not include if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan to prevent the person in care from leaving.
      • Does not include behavioural intervention, if applicable.
      • Does not include an oral health care plan.
      • Does not include a recreation and leisure plan.
    • Care plan(s) is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care or at least once a year [RCR Sec 81(4)(b)]
      • Care plan(s) are not reviewed at least once a year.
    • All persons admitted comply with the Province's immunization and TB control programs[RCR Sec 49(1); DOLSOP]
      • Immunization status on admission is not reviewed (DOLSOP)
      • Clear and up-to-date records of the immunization status of each person in care is not kept.(DOLSOP)
    • When a manager resigns or is absent for more than 30 consecutive days notification to Community Care Facilities Licensing has been given and there is a replacement [RCR Sec 8(3)]
      • Notification has not been given.
    • The facility has written policies and procedures as prescribed by the regulation [RCR Sec 85(2)(b-l)]
      • There is no written policy and procedure for the use of restraints in an emergency.
      • There is no written policy and procedure on the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
      • There is no written policy and procedure on the steps to be taken if a person in care leaves, or may have left, the community care facility without notification of an employee.
      • There is no written policy and procedure regarding release of vulnerable adults from the community care facility if a person who is not authorized to remove the person in care from the community care facility requests the release of the person in care.
      • There is no written policy and procedure to monitor the nutrition of a person in care.
      • There is no written policy and procedure on access to persons in care by persons who are not employees of the community care facility.
      • There is no written policy and procedure regarding release of vulnerable adults from the community care facility, including if a person who is authorized to remove the person in care from the community care facility appears to be incapable of providing safe care to the person in care.
      • There is no written policy and procedure on the appropriate manner and schedule of record keeping.
      • There is no written policy and procedure for responding to reportable incidents.
      • There is no written policy and procedure regarding how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60 [dispute resolution].
      • There is no written policy and procedure regarding continuing education of managers and employees.
    • The facility keeps a record for each person in care with the information specified by the regulation [RCR Sec 78(1)]
      • Files lacks immunization status.
    • Employee files contain the records required by this regulation [RCR Sec 86]
      • Does not contain criminal record check results.
      • Lacks record of any performance reviews made under section 40 [continuing monitoring of employees]
      • Lacks record of any attendance at continuing education programs.
    • A record respecting complaints made and concerns expressed to the licensee under section 60 [dispute resolution], and the responses to them is kept [RCR Sec 89(1)]

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