Gateway Crisis Stabilization Unit
3rd Floor-517 6 Ave N Williams Lake BC V2G 2G8 · Residential Care - Licensing
10 inspections
- Routine Inspection
1 infraction
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Person in care records do not contain the emergency consent required by the Residential Care Regulation. This written consent is to call a medical or nurse practitioner or ambulance in case of accident or illness. Licensing must receive written confirmation that this consent has been added to person in care records no later than February 18, 2026.
- R4.1L - 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)
- R4.1 - Are person in care records current, complete and kept confidential?
- Routine Inspection
0 infractions
- Routine Inspection
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): In discussion with the facility manager it was learned that a service delivery problem has recently occurred and requires reporting.
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Persons in care do not currently have access at all times to an employee who holds a valid first aid and CPR certificate.
- R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Two of four person in care records reviewed did not include immunization status.
- 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
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
3 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The name of the facility manager must be posted in a prominent place. As per section 11(1)(a) of the RCR. The most recent routine licensing inspection must be posted in a prominent place. As per section 11(1)(b) of the RCR. The rights of adult persons in care (Bill of Rights) must be posted in a prominent place. As per section 7(1)(c.1) of the Act. Self-monitoring was discussed with the facility manager. While some aspects of the physical environment and care/supervision services are monitored regularly, there is no formal system in place to ensure all requirements of the Act and RCR are being met.
- 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)
- R1.1W - 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)
- RB1.19 - Are rights of adult persons in care displayed in a form and in the manner acceptable to the minister?
- Observation(s): BOR currently not posted.
- 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): BOR currently not posted.
- 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?
- Routine Inspection
1 infraction
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): LO Vermeulen discussed with both the facility manager and team lead, the requirements with respect to incident reporting. Reportable incident definitions and the process of reporting were reviewed. The manager indicated that there may be some incidents in the recent past that will require reporting. Please provide a written plan describing how all staff will be informed of the legislative requirement to immediately notify Licensing of reportable incidents (Schedule D) and the system for reporting.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
1 infraction
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): LO Vermeulen and facility manager discussed the requirement to regularly self-monitor the physical environment and services provided to ensure compliance with the Act and Residential Care Regulation. Currently there is no system in place.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
1 infraction
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): LO Vermeulen discussed staffing requirements. At this time, performance appraisals have not been completed as per the facility's three year policy. Please inform Licensing as to what system will be implemented to ensure compliance. Criminal record checks expire after five years. The team leader states that she was unaware of this. Please inform Licensing as to what system will be implemented to ensure compliance.
- R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Facility has a manager who has been in place for over 30 days, please inform Licensing in writing regarding the new mangers start date and contact information.
- R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Staff performance evaluations for some staff are overdue, facility policy for regular staff is to complete performance evaluations every three years, inform Licensing on how the overdue evaluations will be caught up and what systems will be in place to keep evaluations up to date.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
3 infractions
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Facility has been without a manager for more than 30 days without notification of Licensing. Inform Licensing in writing regarding the new facility manager
- Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance evaluations for some staff are overdue, facility policy is regular performance evaluations every 3 years, ensure performance evaluations are completed in compliance with facility policy. Inform Licensing on when overdue staff performance reviews will be completed.
- Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Video cameras in use in several hallways and common areas, ensure signage is provided to notify public and residents of cameras use.
- 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 ( 13 )
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
3 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): MARs do not always document the effectiveness of PRN medications, current practice indicates when PRN's are not effective they are charted in nurses notes. Ensure consistent procedure is established to document the reason and result of all PRN's administered.
- Keep a medication administration record showing all medications administered to the person in care; 78(2)(a)
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): Some PIC records reviewed during this inspection had no information available regarding PIC's immunization history.
- Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (13)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Staff backpacks and purses stored in an area that is accessible to PIC's, ensure these items are stored securely to prevent PIC's from potentially accessing hazardous materials (medications, lighter, sharp utensils etc..)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?