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Mariposa Court

3419 Mariposa Ct Kelowna BC V1W 2S9 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    0 infractions

  2. Routine Inspection

    1 infraction

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): A review of PRN documentation indicated that the effects of the PRN was not being consistently documented.
      • R4.2E - Keep records of compliance with section 70 (administration of medication); 89( 2 )(d)
  3. Routine Inspection

    0 infractions

  4. Routine Inspection

    2 infractions

    • RB1.16 - Are persons in care who make prepayments provided written terms and conditions under which a refund may be made?
      • Observation(s): See question R2.1 that has been noted on this report.
      • RB1.16A - Ensure persons in care who make prepayments are provided written terms and conditions under which a refund may be made.
    • 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): There is no known repayment agreement in use or a record of each person to whom it has been delivered.
      • R2.1AC - Keep a copy of the written statement, referred to in section 19 of the Act, that the licensee delivers to persons who prepay part of the cost of services; 85.1 ( 2 ) (a), Act 19
      • R2.1AD - Keep a current record of each person to whom the written statement is delivered as referred to in section 19 of the Act; 85.1 ( 2 )(b)
  5. Monitoring

    0 infractions

  6. Monitoring

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): May 30, 2017 -It was noted that a system is not in place to ensure that incidents involving emergency restraints are 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): May 30, 2017 -It was noted that a system is not in place to ensure that emergency restraint follow-up and documentation is in place. An emergency restraint was implemented on February 18, 2017 and the person in care's care plan or record did not include documentation to support that information had been provided to the person in care in regard to the use of the emergency restraint.
      • R10.4H - Provide in a manner appropriate to the person in care's skills and abilities, information and advice in regard to the emergency restraint used; 73( 3 )(a)(i)
      • R10.4K - Document in the care plan, the advice and information given following the use of an emergency restraint; 73( 3 )(b)
  7. Monitoring

    4 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): February 2, 2016 -It was noted that the influenza immunization status of the persons in care was dated 2012. CORRECTED DURING INSPECTION - The manager obtained and placed the current influenza immunization status in the person in care's charts.
      • 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
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): February 2, 2016 -It was noted that the influenza immunization status of the persons in care was dated 2012. CORRECTED DURING INSPECTION - The manager obtained and placed the current influenza immunization status in the person in care's charts.
      • 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
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): February 2, 2016 -It was noted that the floor in the exercise room was covered with salt, and it appeared that a water leak had occurred at some point.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
    • 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): February 2, 2016 -It was noted that a nutrition plan could not be located in one person in care's chart. CORRECTED DURING INSPECTION - The manager generated the nutrition plan and placed it in the person in care's chart. It was noted that one person in care's care plan contained outdated information regarding assistive equipment. -It was noted that one person in care's care plan contained a behaviour management/safety plan that stated review was due over one year ago. THE MANAGER REPORTED THAT THE BEHAVIOUR MANAGEMENT/SAFETY PLAN IS OUTDATED AS THE FACILITY IS WAITING FOR IT TO BE COMPLETED BY THEIR FUNDING PROGRAM.
      • 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)
      • 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)
  8. Monitoring

    7 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): 18-Mar-2015-It was noted that the Incident Report Policy did not include "choking' and "aggression between persons in care". Corrected During Inspection 18-Mar-2015-It was noted that the in-house Incident Report binder did not include "choking" and "aggression between residents". Corrected During Inspection
      • Ensure there are written policies and procedures regarding responding to reportable incidents; 85(2) (j)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): 18-Mar-2015-It was noted that an incident of "Service Delivery Problem" in July 2014 was not reported to Licensing
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
      • Retain a record of reportable incidents involving persons in care; 88(c)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • 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
    • 17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): Does not apply to Community Living.
    • 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): 18-Mar-2015-It was noted that the Mariposa House Policies inspected had a review date of 2006. 18-Mar-2015-It was noted that the Hildebrandt Home Disaster/Fire Policy had a review date of 2013.
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): 18-Mar-2015- Admission height and weight for one PIC was placed in their chart during inspection. 18-Mar-2015-Influenza vaccine records for all PICs were placed in the PIC's charts during inspection.
      • Record the height and weight of each person in care on admission; 49 (2)
      • 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
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 18-Mar-2015-It was noted that painting was not finished in one PIC's room. -It was noted that walls are patched and require painting in the recreation room. -It was noted that one PIC's room had 2 holes in the wall. (It was reported by the manager that this room had been repaired recently and that these holes were new. -It was noted that the ceiling fan in the downstairs bathroom required cleaning, and that one PIC's floor required cleaning (It was reported by the manager that there is a cleaning schedule for these rooms, and that they are cleaned by the PIC who uses them. The manager reported that a plan will be put into place to monitor the cleaning, and that the staff will be educated) 18-Mar-2015-Outdoor lounging area inadequate-This remains UNRESOLVED since 14-Apr-2011 RCR 36 - A licensee must provide outside activity areas that have (a) in total, at least 1.5 m2 of space for each person in care, (b) a surfaced patio area, and (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather.