Skip to content
Loading map…

Sandalwood Adult Intensive Care Facility

2965 Westsyde Rd Kamloops BC V2B 7E7 · Residential Care - Licensing

13 inspections

  1. Routine Inspection

    2 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Menus are written on a five-week rotation but are not adjusted for seasonal changes. When menu items are not provided as per the season, variety of foods is limited and could lead to persons in care having a reduced appetite. Submit a detailed corrective plan of how you will ensure the Licensee has taken into consideration seasonal variety in the menus by September 4, 2025.
      • R5.1G - Provide a variety of foods in consideration of seasonal variations; 62( 2 )(c)(iii)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Fridge and freezer temperatures are regularly documented, and temperature ranges are indicated on the documentation record. Multiple temperatures that had been documented were outside the indicated range. The manager reported there is not a current system in place to review the temperatures or a process to guide staff to report when temperatures are not in the acceptable range. When fridge and freezer temperatures that are not within acceptable ranges are not reported, this could lead to improper storage of foods, leading to illness for persons in care. Submit a detailed corrective plan of how you will ensure fridge and freezer temperatures are reported when not within the indicated range by September 4, 2025.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  2. Routine Inspection Follow-up

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): -Records of immunization control programs including Hep B vaccine and evidence of annual flu shots/decline to receive annual flu shots were found in approximately half the employee files reviewed. Evidence of Covid vaccinations was present in all files. -One of the employee files reviewed had evidence of tuberculosis control programs screening, while no evidence of tuberculosis screening was not present in any other employee files. -The Licensee designate present at the inspection was not familiar with what the current provincial immunization and tuberculosis control program included. -Of the employee files that were reviewed two files showed no evidence of a performance review having been complete as per the policy of the organization. -Of the employee files reviewed, three files had first aid/CPR certificates which did not meet the requirements of Schedule C. The course taken did not include an "in person" portion, as it was an online program which does not meet Schedule C. Please be sure to fully review Schedule C when selecting a "preferred" first aid/CPR program for the organization.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • R3.1N - 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)
      • R3.1R - 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)
  3. Routine Inspection

    2 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): A review of the current menus showed that there are meals where there are only two food groups are being provided during the meal. A review of the current menus showed that there are snacks where only one food group is being offered. Three snacks per day are being offered (morning, afternoon and evening). The facility does not currently have an auditing process to ensure the menus planned have sufficient food group offerings per day for persons in care, as per the Canada Food Guide, and the "Meals and More" guide book indicate are required.
      • 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)
      • 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)
    • 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): A review of person in care's files showed no evidence that the "personal service plan" (PSP) had been reviewed on an annual basis, which is part of the overall care plan for each person in care.
      • 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)
  4. Routine Inspection Follow-up

    2 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance reviews were reported by the Licensee to not yet be up to date and/or completed for staff and the plan is still in progress to come into compliance. This is a repeated contravention and the listed target date was not achieved per previous compliance plan.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One bathroom within the facility has a square hole cut out in the ceiling above the toilet, exposing drywall and dust to persons in care. In one bathroom, the sink had four areas each measuring approximately 1.5cm diameter where there was no longer porcelain finish present, and metal beneath was exposed. There were bedrooms of persons in care which were in a state of renovation with patched holes, and were being readied for paint. There were electrical outlets without covers present in one of the person in care's rooms. One room had a closet with the door removed or broken, which led to an unfinished storage area with two nails sticking out of a board at head height. Please ensure there is an ongoing process for maintenance needs to be monitored and areas are repaired within a reasonable amount of time in order to maintain the facility in a good state of repair. This is a repeated contravention of general maintenance.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  5. Routine Inspection

    7 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): There was no non- slip surfaces present in either of the laundry areas, where PIC are able to use the laundry facilities. Please ensure the area of the laundry facilities where persons in care may be present has a non-slip surface.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): During the inspection it was noted that several tools which the facility used to monitor the environment were incomplete or not completed at all. Examples include: fridge temperature checks, menus which did not meet the basic criteria of the legislation, and ongoing physical maintenance issues not yet addressed (walls not having repairs completed and no plan available at time of inspection). Please ensure the Licensee and/or designate are completing regular self monitoring of all facility systems to continually assess for compliance with applicable legislation.
      • 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): There was evidence of a Fire Drill having been completed for March 2023, but there was no evidence provided for drills having been completed in January or February, and no reason why they were not completed. Please ensure your systems to monitor the emergency plans are followed to ensure regular practice of emergency procedures for the facility, including at minimum an annual evacuation drill.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff performance evaluations are overdue, this contravention was noted on a previous licensing inspection within the last three years, but due to manager change over several times this year, the reviews have fallen behind again. Please submit a plan on how the performance reviews will be kept up to date. Please ensure all staff have their performance and competency evaluated on a regular basis, as per facility policy.
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The facilities current menus were reviewed during the inspection and it the following was noted: -Some of the meals did not include at least three food groups listed on the menu -One snack per day was listed on the menus, and several snacks only listed one food group. Per manager, the morning snack was not listed as the PIC attend "day programs", but there is nothing indicating that is the reason for not listing the morning snack. The facility has blank substitution lists available, but no evidence this has been used for actual substitutions. Please ensure all menus are reviewed to ensure the legislation criteria is met. And ensure staff are using the Substitutions List in order to ensure persons in care are receiving appropriate substitutions to meet nutritional requirements.
      • 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)
      • 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)
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Temperature tracking sheets were present on fridge/freezers in the home that contain PIC food, but one sheet was dated as "October 2022" and others had no dates on them to show what month/year was being monitored to ensure food is being stored at optimal temperatures. Please ensure all facility auditing is completed as required by facility policy.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): In the main living area of one of the downstairs suites had several drywall patches present. Manager was unable to inform if there was a plan to complete the repairs. *This is a repeated contravention from previous inspections within the last three year history. Most previously mentioned areas requiring maintenance were recently painted and in good repair at this inspection, other than observed areas. Please ensure all areas of the facility are monitored for damages and reported and repaired within a reasonable time in order to maintain the facility in a good state of repair.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  6. Routine Inspection

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Monthly occupational health and safety checks are in place to monitor the physical facility, however the identified physical deficiencies are not being addressed (see below RCR s. 22).
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The following deficiencies to the physical facility were observed: - Living room - multiple areas of unpainted spackle wall patching (noted during previous inspection and unresolved). - One Person in Care bedroom - multiple areas of unpainted spackle patching. - Unpainted plywood wall protectors noted in living room and kitchen. - Unshielded light fixtures in two areas. - Ceiling peeling in kitchen area above stove. - Broken cabinet in washroom; cracked and worn cabinet facings in kitchen. - Hole in door near side entrance above stairs to lower area of facility. - Exterior areas: - lawn uncut, lawn furniture dusty, mailbox not secured, bedframe stored beside fence in driveway, and picnic table and raised garden beds in disrepair. At the time of inspection front lawn was being mowed and some yard waste was being removed.
      • 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)
    • 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): A Person in Care (PIC) was involved in a reportable incident in April 2022. Updates were made to the PIC's care and supervision, however the care plan was not updated as required.
      • 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)
  7. Routine Inspection

    4 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff performance evaluations are overdue, this contravention has been noted on three consecutive inspections.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): A process to weigh each person in care at least once a month is not in place.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): One fridge/freezer in the house is monitored daily for temperatures, two other fridge/freezers in the home that contain PIC food are currently not being monitored to ensure food is being stored at optimal temperatures.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Living room area on one side of the building has many areas of patch on the walls due to drywall repairs, this was noted as requiring follow-up during the last routine inspection at the home. Inform licensing on what systems are in place at the facility to deal with ongoing wear and tear to the home, as well as what follow-up will be completed in the living room area.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  8. Routine Inspection

    2 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff performance evaluations are overdue, this contravention was noted on the last licensing inspection and the facility did catch up on reviews, but due to COVID issues the reviews have fallen behind again. Please submit a plan on how the performance reviews will be kept 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Living room area on one side of the building has several holes in the drywall and many patches, inform licensing on the timeframes for repairing drywall and re-painting the room. Flooring in the downstairs portion of one side of the home has been removed due to previous flooding of the area, inform licensing on the timeframes for replacing the floor.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  9. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Facility physical self monitoring documentation still does not include wear and tear items which will need repair or replacement in the future (downstairs flooring, kitchen ceiling and lounge area walls chipped and in need of paint/repair), this item was noted during the last Licensing inspection.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff annual performance evaluations are all overdue, this contravention was noted during the last Licensing inspection at this site in July 2018. Inform Licensing on what processes will be put in place to ensure performance evaluations are completed on schedule.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One closet door was observed off the hinges in the downstairs portion of the facility, another closet door was observed leaning against the wall in the same area of the facility which could be dangerous if bumped or knocked over by a PIC or staff.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Ensure PIC's who may leave the facility independently have identification which includes their name, facility name and emergency contact information.
      • R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
  10. Monitoring

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Facility physical safety checks was noted as incomplete on the last Licensing inspection, items noted during this inspection included: broken light switch, door bell chime hanging improperly on the wall, broken cabinet in the kitchen, carpet tack strip exposed around a post in the basement of the home, closet door leaning against a wall and ceiling cracking and chipping in one of the homes kitchens. After the last Licensing inspection, a response was received from the facility indicating a monthly checklist had been created to review and repair wear and tear to the facility.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The staff qualification checklist reviewed during this inspection indicate the CRC for one staff had recently expired, what processes are in place to ensure staff renew required items before they expire. Staff regular performance evaluations are overdue, inform Licensing on what processes will be put in place to ensure performance evaluations are completed on schedule.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Carpet in the downstairs den and hallway on one side of the building was removed in the summer of 2017 due to a water leak in the basement, Licensing noted this as needing attention on July 20, 2017; Licensing received correspondence from the facility on July 25, 2017 indicating the flooring would be replaced by November 1, 2017. The flooring has not been replaced at this time. Inform Licensing on when/how this item will be addressed. Several carpet tack strips are still located in the den area where carpet was removed, ensure these are removed to prevent potential injury to a PIC. Ceiling cracking and chipping in the kitchen on one side of the building (noted on last Licensing inspection) and one cabinet in the same kitchen has a hole in the door. Inform Licensing on how/when these items will be repaired. One item noted under the kitchen sink indicated on the label that it contained hazardous materials and should be kept inaccessible, a storage room door in the basement of the facility was observed open at the time of this inspection, the room contained several cleaners which should be kept inaccessible to PIC's. Inform Licensing on what systems/audits will be put in place to ensure potentially hazardous materials are kept inaccessible to PIC's at all times.
      • 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)
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  11. Monitoring

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Facility physical environment safety checks are currently being conducted, please include in these checks areas that are showing wear and tear; observed during this inspection (ceiling cracking and chipping in kitchen area on one side of the building & kitchen cabinets in both kitchens have visible damage). Current physical environment checks are not capturing general wear and tear to the facility.
      • 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): Please review current emergency plans to ensure procedures are in place to facilitate evacuation out of the community if needed, and how residents would continue to be cared for during the evacuation. Include in your response how often the plan will be reviewed and how you will ensure staff are always trained on current procedures.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Ceiling cracking and chipping in kitchen area on one side of the building & kitchen cabinets in both kitchens have visible damage, inform licensing on the plan to address these issues. Carpet in the downstairs den and hallway on one side of the building was removed due to a water leak in the basement. Inform Licensing on when the flooring will be replaced.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  12. Monitoring

    2 infractions

    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Several staff are overdue for their performance reviews, this infraction was also noted on the last licensing visit to the site. Inform Licensing in writing on the date in which all overdue staff performance evaluations will be completed.
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Carpet in the downstairs area on one side of the house has stains, some drywall in this portion of the home is also damaged due to recent water damage. A hole in the wall in one hallway needs repair. Paint in the living room on one side of the building is scraped and chipped and needs re-painting. One refrigerator in the home had visual stains on the door and on the bottom drawer, ensure these areas are cleaned. The facility manager will also be reviewing facility cleaning procedures and ensuring all staff are aware of any changes to the current procedures.
      • 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)
  13. Monitoring

    4 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Laundry area requires a slip resistant material or mat as PIC's access this area to help with laundry.
      • Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Ensure recreation opportunities within the home are made available daily for PIC's and that activities are documented in PIC individual notes for review.
      • Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Facility Manager indicates all new staff have received a performance evaluation but some of the senior staff have not received a performance evaluation in the last year. Facility policy is to conduct annual performance evaluations on all staff, please submit a plan to Licensing by July 17, 2015 on when all evaluations will be up to date.
      • 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)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Thermometer is one refrigerator not functioning properly, ensure the thermometer is replaced to have food stored between 0 and 4 degrees Celsius.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 5 )