Skip to content
Loading map…

The Hamlets at Penticton

103 Duncan Ave W Penticton BC V2A 2Y3 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Unlocked cupboard accessible to persons in care contains scissors, betadine solution and a bottle of foam spray wash. On another unit, a counter accessible to persons in care contains a used glove, and wheelchair pedals on top of a chair. Unsecured hazardous materials pose a significant risk of harm to persons in care through accidental exposure, ingestion or injury. Please submit a corrective action plan by February 9 , 2026 advising how all areas accessible to persons in care will contain secure and safe storage for hazardous materials.
      • 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)
  2. Routine Inspection

    5 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing Officer reviewed three charts for persons in care, two of which did not comply with the Province's immunization and tuberculosis control programs. A system has already been put in place to ensure compliance going forward and an audit will be conducted for the current persons in care. The contravention will be resolved as corrected during inspection.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing did not receive notification of a manager change that occurred on September 2, 2024.
      • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(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): Licensing Officer reviewed the restraint monitoring records. There were several instances where the monitoring was not recorded in a manner that followed the policies and procedures. Licensing Officer reviewed the monthly weight records. As per the policies and procedures, one section of the facility did not properly record the monthly weights for July of 2024.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed three fridges containing food items for persons in care, not labelled with usage dates. Licensing Officer observed a recreational fridge which was not properly recording fridge temperatures, ensuring food is safely stored.
      • 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): Licensing Officer observed a snow shovel, wooden trim with nails, a wheelbarrow, and a ladder accessible to persons in care and not properly stored.
      • 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)
  3. Routine Inspection

    5 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): Licensing Officer observed safety check documentation that showed staff were not always implementing facility policy; either by not properly documenting the safety checks or not completing them at the frequency required. Although staff appeared to be aware of proper processes, there was no evidence of a documented plan for how to mitigate, respond, or recover from a possible forest fire evacuation. Comment: Licensing Officer was informed prior to the inspection that not all of the policies and procedures had been reviewed/revised annually but a plan to ensure compliance was already in process.
      • 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)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing Officer observed the snack menu which did not contain two nutritious snacks. The snack menu contained one snack for every day of the week, being juice, milk, and cookies.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed refrigerators used in dining and recreation areas where the temperatures were not being monitored.
      • 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): Licensing Officer observed a dining room wall that was not in a good state of repair. A plan was implemented during the inspection to ensure compliance.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer did not observe a system to ensure persons in care were encouraged to be examined by a dental health care professional at least once a year.
      • R10.2H - Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 3 )(a)
  4. Routine Inspection Follow-up

    1 infraction

    • 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): Licensing Officer observed the restraint safety check documentation. It was observed that the removal of restraints were not documented as per policy. Licensing Officer observed that there was no system to monitor required education and training is completed by staff. Licensing Officer observed the high risk rounds which were not documented as per policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1U - Ensure there are written policies and procedures for continuing education of managers and employees; 85( 2 )(c)
  5. Substantiated complaint

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Allegation – The Licensee is in non-compliance with Residential Care Regulation (RCR) 76(1). The allegation was investigated through the review of confidentially submitted documentation and and correspondence with the licensee contacts. As a result, licensing found no evidence of notifications as required when a person in care became ill or injured. The allegation that the Licensee is in non-compliance with RCR 76(1) is substantiated.
      • R4.5A - Immediately notify the parent, representative or contact person if a person in care becomes ill or injured while under the care or supervision of the licensee; 76 ( 1 )
    • 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): Allegation – The Licensee is in non-compliance with Residential Care Regulation (RCR) 82. The allegation was investigated through the review of confidentially submitted documentation and correspondence with the licensee contacts. As a result, licensing found no evidence ensuring a certain directive on a care plan was implemented between November 10, 2023 and December 1, 2023. The allegation that the Licensee is in non-compliance with RCR 82 is substantiated.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  6. Substantiated complaint

    2 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): Allegation – The Licensee is in non-compliance with RCR 42(1)(b). The allegation was investigated through the review of confidentially submitted documentation and a site visit. As a result, licensing found that six baths were missed between January 25, 2023 and February 5, 2023, therefore the allegation that the Licensee is in non-compliance with RCR 42(1)(b) is substantiated. Allegation - The licensee is in non-compliance with RCR 42(1)(b). The allegation was investigated through the review of confidentially submitted documentation and a site visit. As a result, licensing found documentation that laundry was being done as per policy. In addition, licensing saw no evidence during a site visit that dirty clothes were being worn by the persons in care, therefore the allegation is unsubstantiated.
      • R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Contravention arising from the complaint investigation, RCR 77(2)(c). It was found during the investigation that licensing was not notified of a reportable incident concerning a service delivery problem.
      • 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)
  7. Routine Inspection Follow-up

    3 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): A restraint was being implemented on a person in care without an emergency or written agreement.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The system to ensure equipment used by persons in care was compatible and met their needs was ineffective.
      • R7.2L - Ensure all furniture and equipment used by persons in care meet their needs; 21(a)
    • 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): Licensing Officer observed a care plan that was reviewed twice and both reviews did not identify a restraint that was being implemented by staff. A restraint was being implemented for a person in care that was not described in the care plan.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  8. Routine Inspection Follow-up

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Licensing Officer observed incident reporting policies that contained incomplete and incorrect information.
      • R2.2F - Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer observed a care planned bed alarm that was not installed for a person in care due to staffing issues.
      • R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): A restraint re-assessment date was detailed in the care plan but the Licensing Officer observed no evidence that this re-assessment occurred.
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing Officer observed a monitoring system for safety checks, turn and reposition checks, and procedure and comfort care checks that was ineffective. The system to ensure restraint agreements were completed as per facility policy was found to be ineffective.
      • 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): Licensing Officer observed ten different polices that had not been reviewed or revised in over a year. Licensing Officer observed missing information on a restraint agreement form, this was contrary to facility policy. Licensing Officer observed restraint monitoring documentation that was not completed by staff as per facility policy. Licensing Officer observed two staff files, one agency staff and one permanent staff member. Both of the orientation processes were not complete.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee failed to meet the needs of a person in care regarding care and supervision.
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
    • 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): Licensing Officer observed restraint repositioning checks and safety checks not completed as per the care plan. Equipment was used by staff for a person in care that was not detailed in the care plan.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82