Kamloops Youth Shelter
Confidential · Residential Care - Licensing
11 inspections
- Routine Inspection
1 infraction
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The “Stored Medication Information Form” was reviewed in several persons in care charts. Four forms found to have incomplete documentation of medications returned to persons in care at exit of program. When documentation of medication counts and transfer of medication to persons in care at exit of program is not complete, this may result in a person being discharged from the program without appropriate medications, potentially causing negative health outcomes. Submit a corrective action plan by February 23, 2026, indicating how the licensee will ensure a system is in place to have medication counts and transfer information documented when persons in care exit program.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
3 infractions
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The facility could not provide a substitution list for menu changes during the inspection.
- R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The following are areas of the facility where the facility was not maintained in a good state of repair: -The ceiling in the hallway of the common area near to the kitchen had several medium and large areas where there was staining present -Two bedrooms had several areas of chipped plaster present. The largest area chipped was approximately 2cm x 2cm. -Two bedrooms had no baseboard present under the sinks in the rooms, leaving glue and plaster exposed -One bathroom had caulking that was cracked and discolored in areas -The same bathroom had a behind the mirror cupboard with rust present inside the majority of the bottom of the shelf -The same bathroom had several spots of discoloration present on the ceiling One bathroom had a tub whose surface is scratched and had become deglazed, leaving the tub to appear stained and difficult to clean. The scratched and deglazed surface leave the tub porous and areas where bacteria can gather.
- 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)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): A person in care had blister packs that were not packaged by the designated pharmacy present at the facility. There were several handwritten Medication Administration Records (MAR) present in files reviewed. The facility has no exemptions for either of these practices.
- 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Routine Inspection
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): In one bedroom, where a sink and mirror are located there was cracked caulking and reddish brown coloration was noted on the wall behind the sink and around the faucet.
- 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): Medication Safety Advisory Committee meeting and medication area inspection were last completed on September 14, 2021, per the manager of the facility. Per the size of the facility, one meeting and inspection per year are required.
- R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The handrail on the emergency exit stairs from the second floor of the building has chipped paint and protruding small slivers of wood in some areas. The light fixture above the sink in the upstairs washroom has rust on the base of the fixture.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
1 infraction
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): In reviewing incident reports from the past year it was noted several reports were not received in a timely manner. Expectation is reports to be received within one business day. Please review incident reporting policy to ensure systems are in place for immediate notification of 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
0 infractions
- Routine Inspection
1 infraction
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Regular staff performance evaluations are behind schedule at this time, inform Licensing on how/when the reviews will be up to date and on what systems/audits will be put in place to ensure they are kept on schedule in the future.
- 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
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Facility currently does not have a procedure in place to monitor hot water temperature in areas accessible to the youth in care. Inform licensing on what systems/audits will be put in place to monitor the hot water temperature. Facility has a physical self monitoring procedure in place, but damage to the wall behind the toilet and behind the toilet paper dispenser in the upstairs youth washroom has been present since the last licensing inspection. Inform licensing on when/how the bathroom issues will be fixed.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
3 infractions
- 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): Facility cleaning procedures need to be updated to include specific information regarding the cleaners to be used in various areas of the home, ensure all pre-poured cleaners have labels to identify the type of cleaner and dates as well as any cleaning instructions which may be required.
- 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)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility policy is to have at least annual evaluations of staff performance, facility is currently behind on staff performance evaluations, please submit a plan on how overdue evaluations will be caught up, once caught up the plan should also include a system to ensure reviews are completed annually.
- 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)
- 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): A miscommunication regarding a youths medication was observed during this inspection resulting in a medication being missed. Ensure care plans are updated regarding any medication changes.
- Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)
- 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?
- Monitoring
4 infractions
- 4.5 Are incidents and notifications reported and records retained as required?
- Observation(s): When the facility manager is away the facility does not forward incident reports to Licensing. Please develop a procedure for licensing to always receive reportable incidents within one business day.
- Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Facility has a self monitoring procedure in place. Please update the procedure to include correction dates and completion dates for deficiencies found. Also update the procedure to include checks other than physical such as medication administration reviews and daily log note reviews etc..
- Regularly monitor the physical environment and the care and services provided; 61
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Two staff files reviewed during this inspection were overdue for a performance evaluation. Please review staff files and ensure all overdue staff performance evaluations are completed. Pleases submit a plan of when overdue evaluations 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)
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Documentation available for each youth in care does not always chart meals eaten while the youth was in care. Ensure daily charting for each youth includes food consumed while they are at the facility.
- 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)
- 4.5 Are incidents and notifications reported and records retained as required?
- Monitoring
10 infractions
- 4.5 Are incidents and notifications reported and records retained as required?
- Observation(s): Licensing has been receiving incident reports but they have been coming in late, the expectation is licensing will receive IR's within one business day.
- Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
- 8.1 Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): Develop a recreation program that meets the needs of youth in care.
- Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55(1)(a)(i)
- 8.2 Does the program of activities support individualized care plan requirements?
- Observation(s): Ensure recreation program is designed to meet specific needs of each youth in care.
- 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)
- 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): Medication procedures must be reviewed to include specifics on how/where staff dispense medication. Ensure youth who are staying at the facility for more than 30 days have a plan in place to regularly monitor nutrition.
- Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68(3)(b)(i)
- Ensure there are written policies and procedures regarding monitoring nutrition of persons in care; 85(2)(g)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Ensure all staff are trained on facility medication administration procedures.
- Ensure all employees who store, handle and administer medications are 19 years of age or older and have successfully completed a training program established by the medication safety and advisory committee; 70(2)(a)(b)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Ensure care plans are developed for all youth who reside in home for more than 30 days. Ensure each PIC in care over 30 days is weighed monthly and information is used in conjunction with their nutrition plan.
- Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
- Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83(4)(a)(c)
- 4.6 Are facility records current and complete?
- Observation(s): Current menu only includes dinner, due to the type of care provided scheduling of only dinner meals may be appropriate however each youth in care must have daily logs that include what was eaten for breakfast, lunch, dinner and two snacks if they are in care all day. Ensure meals are in compliance with Canada Food Guide (four food groups meals, two food groups snacks).
- Retain food services records of menus and menu substitutions; 87(b)
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Ensure education procedures regarding influenza control (poster/masks) are available for visitors to the facility.
- Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Curtain rod and paper towel holder in main washroom both broken, window screen in one bedroom missing. Establish cleaning procedures for youth in care bedrooms that include laundry for clothes and linens (timeframes). Procedures should also include cleaning of rooms (sinks, flooring). If youth are staying for extended period of time ensure closets and cabinets are used for storage of PIC belongings.
- Maintain all rooms and common areas in a good state of repair; 22(1)(b)
- Maintain all rooms and common areas in a safe and clean condition; 22(1)(c)
- 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): Please review Residential Care Regulation 81-83 and ensure each care plan for youth who reside in care longer than 30 days is in compliance with requirements.
- 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)
- Care plans must include a plan to address behavioural intervention, if applicable; 81(3)(a)(ii)
- Care plans must includes an oral health care plan; 81(3)(b)
- 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)
- Care plans must include a recreation and leisure plan; 81(3)(d)
- Each care plan must be monitored on a regular basis to ensure proper implementation; 81(4)(a)
- 4.5 Are incidents and notifications reported and records retained as required?