Steller's Jay House
4200 17 St Vernon BC V1T 8R7 · Residential Care - Licensing
8 inspections
- Routine Inspection
3 infractions
- 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): The system to ensure that all policies and procedures are followed is ineffective. A review of the Keyworker checklists identified checks for a multitude of monthly tasks pertaining to persons in care were not signed as per policy. Incomplete checklists may indicate that processes and checks were not completed as required. Submit by July 24, 2026, the plan that will be implemented to come into compliance with Section 85(1)(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system to ensure that work areas are safe and secure is ineffective. During the inspection of the facility, a hallway cupboard was noted to be unlocked and accessible to persons in care. The cupboard contained multiple bottles of alcohol based hand-sanitizer’s . Unlocked cupboards which contain hazardous material may increase risk to persons in care as the products may be used incorrectly or ingested and cause adverse reactions. Submit by July 24, 2026, the plan that will be implemented to come into compliance with Section 35(1)(c) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- 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)
- 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): The system to ensure that care plans are reviewed and if necessary modified when required or at least once a year is ineffective. During the review of care binders, it was identified that a variety of care plans, HCL Service, Oral service, Behavioural Support and Nutritional plans, had not been routinely reviewed and if necessary, updated, to ensure they continue to reflect the current needs of the individuals in care. Failure to update care plans can result in care that does not reflect the person's current needs or condition. This increases the risk of staff not having accurate guidance to provide safe and effective care. Submit by July 24, 2026, the plan that will be implemented to come into compliance with Section 81(4)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- 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)
- 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?
- Routine Inspection
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system to ensure that water accessible to persons in care is not heated to more that 49 degrees Celsius is ineffective. Water temperature checks in two locations were in excess of 49 degrees. Water temperatures exceeding 49 degrees Celsius presents risk for immersion burn. Submit by July 25, 2025, the plan that will be implemented to ensure ongoing compliance with Section 17 of the Residential Care Regulation. During the inspection of the physical facility, the door to the laundry room was noted to be unlocked and accessible to persons in care. A storage cupboard containing cleaning agents, chemical products and other hazardous materials were easily accessible. Access to laundry facilities not used by person in care poses several risks to persons in care, especially those who may have cognitive impairments or other vulnerabilities. Submit by July 25, 2025, the plan that will be implemented to ensure ongoing compliance with Section 35(2)(b) of the Residential Care Regulation.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R7.1AM - Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 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): The system to ensure that a nutrition plan for each person in care is developed is ineffective. A review of Care plans identified that not all persons in care had a nutrition plan. Failure to develop a nutrition plan for each person in care can compromise staff's ability to meet persons in care's current and individual nutritional needs. Submit by July 25, 2025, the plan that will be implemented to ensure ongoing compliance with Section 83(1)(a) of the Residential Care Regulation.
- R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
2 infractions
- 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): The system to review policy and procedures relating to medication is ineffective. A review of the Medication Safety and Advisory Committee (MSAC) policy and procedure binder identified outdated information.
- R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system for maintaining the physical environment is ineffective as noted by a bathroom shower requiring painting and holes in a bedroom wall where a TV was previously fixed.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- 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?
- Routine Inspection
4 infractions
- 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): The policy to ensure that new managers are orientated to the regulations and act was ineffective. New manager has received no orientation to the Community Care and Assisted Living Act or Regulation.
- R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): During a chart review, it was identified that several monthly weights were not recorded.
- 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): In reviewing the weekly menu it was observed that snacks were not listed. Please ensure posted menus include information on the daily snacks provided.
- 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): During review of care plans, it was identified that a care plan did not include a nutrition plan. Please ensure that care plans contain all the required components of a care plan.
- R10.3E - 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)
- 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?
- Routine Inspection
0 infractions
- Routine Inspection
2 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): During the inspection, it was noted that the current laundry room did not have a slip-resistant surface. One person in care does assist with laundry.
- R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
- 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): During the inspection, it was noted that the emergency plan was not up to date and did not reflect the recent renovations that were completed in May 2019.
- R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
- R7.2 - Is the environment maintained to prevent falls?
- Monitoring
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system for ensuring compliance with water temperature is ineffective. The water temperature taken by the Licensing Officer today read between 58 - 60 degrees Celsius. The Program Coordinator turned the temperature down on the hot water tank today during the inspection and will continue to monitor the temperature to ensure the correct temperature is reached.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
3 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The system for ensuring compliance with Medication Administration Records is ineffective. There was a missed signature on one of the regularly scheduled medications for today. The staff member on duty signed the Medication Administration Record. This item was corrected during the inspection.
- Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- 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): The system for ensuring compliance with implementing policies is ineffective. There was no documentation available to confirm that monthly fire drills were completed in September or October of 2016.
- Ensure policies are implemented by employees; 85( 1 )(d)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): The system for ensuring compliance for completion of records is ineffective. Signed consent was missing from one of the records in regards to contacting the medical or nurse practitioner or ambulance in case of accident or illness.
- 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)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?