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Victory House - Mental Health

353 E Cordova St, Vancouver BC V6A 1L4 · Mental Health

Official record from Vancouver Coastal →

Inspection summary

Victory House - Mental Health has been inspected 9 times by Vancouver Coastal Health since November 10, 2021. The most recent inspection, on May 20, 2026, recorded 7 infractions.

None of the 9 inspections on record were free of infractions. In the past 12 months there was 1 inspection with 7 infractions recorded. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

Recent inspections have recorded fewer infractions than earlier ones, so the record is improving.

What these findings mean

Health authorities word their findings differently, so we group them by what they mean for your health. Higher-risk findings are the ones inspectors treat as critical, because they can directly make someone sick.

  • Permits, records and postingLower risk

    Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.

    Recorded 36 times across 9 separate inspections, most recently on May 20, 2026. For example: For each person in care, there is a record showing the date of admission, and the consent to be admitted or to continue to be accommodated. [RCR Sec 77.1(1)(a)(b)]

  • Building, plumbing and upkeepLower risk

    Floors, walls and ceilings must be clean and in good repair, with working lighting, ventilation, plumbing, hot and cold water, and washrooms. These are rarely an immediate health risk on their own, but persistent problems can lead to pest or sanitation issues.

    Recorded 7 times across 7 separate inspections, most recently on May 20, 2026. For example: Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]

  • Food safety training and certificationLower risk

    Many jurisdictions require a trained or certified person on site, such as a certified food handler. These findings mean the training record or the trained person was missing at the time. They do not by themselves mean anything was handled unsafely.

    Recorded 3 times across 2 separate inspections, most recently on May 20, 2026. For example: Persons in care have at all times immediate access to an employee who is certified in first aid and CPR, knowledgeable about their medical condition and able to communicate with emergency personnel [RCR Sec 43(1);DOLSOP Preventing Opioid Overdose]

  • Equipment and utensilsLower risk

    Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.

    Recorded 2 times across 2 separate inspections, most recently on May 20, 2026. For example: Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]

  • Other findingsLower risk

    Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.

    Recorded 8 times across 3 separate inspections, most recently on December 1, 2023. For example: There is a MSAC with the appropriate membership [RCR Sec 68(1)]

About this data

These results come from Vancouver Coastal Health, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.

9 inspections

  1. Routine

    7 infractions

    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
      • Employees have not been trained in the emergency plan.
      • Employees have not been trained in the use of emergency equipment.
    • For each person in care, there is a record showing the date of admission, and the consent to be admitted or to continue to be accommodated. [RCR Sec 77.1(1)(a)(b)]
    • There is a record of any assessment of incapability report provided under section 22 (1) (c) of the Health Care Consent Regulation. [RCR Sec 77.1(1)(c)]
    • The most recent routine inspection record is displayed in a prominent place. [RCR Sec. 11(1) (b), (2); Bill of Rights 4(b)]
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
      • Rooms and common areas are not maintained in a good state of repair.
      • Rooms and common areas are not maintained in a safe and clean condition.
      • Rooms and common areas are not well ventilated.
    • The written policies and procedures are reviewed and revised if necessary at least once each year [RCR Sec 85(1)(b)]
    • Persons in care have at all times immediate access to an employee who is certified in first aid and CPR, knowledgeable about their medical condition and able to communicate with emergency personnel [RCR Sec 43(1);DOLSOP Preventing Opioid Overdose]
      • There is lack of immediate access to an employee who is certified in first aid and CPR.
  2. Routine

    6 infractions

    • For each person in care, there is a record showing the date of admission, and the consent to be admitted or to continue to be accommodated. [RCR Sec 77.1(1)(a)(b)]
    • There is a record of any assessment of incapability report provided under section 22 (1) (c) of the Health Care Consent Regulation. [RCR Sec 77.1(1)(c)]
    • Monthly weights are taken and recorded, if missing, the reason is documented. [RCR Sec 83(4)(a),(5)(a)]
      • Monthly weights are not taken.
      • The reason for the monthly weight missing is not recorded.
    • Employee files contain the records required by this regulation [RCR Sec 86]
      • Does not contain criminal record check results.
    • Persons in care have at all times immediate access to an employee who is certified in first aid and CPR, knowledgeable about their medical condition and able to communicate with emergency personnel [RCR Sec 43(1);DOLSOP Preventing Opioid Overdose]
      • There is lack of immediate access to an employee who is certified in first aid and CPR.
    • Employees have experience, competence and training to ensure food is safely prepared, handled and meets the nutritional needs [RCR Sec (44)(1)(a)]
  3. Routine

    1 infraction

    • Reportable incidents have been reported with appropriate notifications [RCR Sec 77(2)(a)(b)(d);DOLSOP Preventing Opioid Overdose]
      • Did not immediately inform the medical health officer.
  4. Routine Follow-up

    2 infractions

    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
    • Employee files contain the records required by this regulation [RCR Sec 86]
      • Does not contain criminal record check results.
  5. Routine Follow-up

    8 infractions

    • The facility has a written policy and procedure for obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility. [RCR Sec 85(2)(m)]
    • For each person in care, there is a record showing the date of admission, and the consent to be admitted or to continue to be accommodated. [RCR Sec 77.1(1)(a)(b)]
      • No record of the consent for that person(s) in care to be admitted.
    • Reportable incidents have been reported with appropriate notifications [RCR Sec 77(2)(a)(b)(d);DOLSOP Preventing Opioid Overdose]
      • Did not immediately inform the medical health officer.
    • The care plan(s) contains all items that must be recorded under this regulation [RCR Sec 81(3)]
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
    • There are written and implemented policies and procedures to guide staff in the care and supervision of the persons in care [RCR Sec 85(1)(a), (d)]
    • The written policies and procedures are reviewed and revised if necessary at least once each year [RCR Sec 85(1)(b)]
    • Employee files contain the records required by this regulation [RCR Sec 86]
  6. Routine

    9 infractions

    • The facility has a written policy and procedure for obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility. [RCR Sec 85(2)(m)]
    • For each person in care, there is a record showing the date of admission, and the consent to be admitted or to continue to be accommodated. [RCR Sec 77.1(1)(a)(b)]
      • No record of the consent for that person(s) in care to be admitted.
    • Reportable incidents have been reported with appropriate notifications [RCR Sec 77(2)(a)(b)(d);DOLSOP Preventing Opioid Overdose]
      • Did not immediately inform the medical health officer.
    • The care plan(s) contains all items that must be recorded under this regulation [RCR Sec 81(3)]
    • Care plan(s) is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care or at least once a year [RCR Sec 81(4)(b)]
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
    • There are written and implemented policies and procedures to guide staff in the care and supervision of the persons in care [RCR Sec 85(1)(a), (d)]
    • The written policies and procedures are reviewed and revised if necessary at least once each year [RCR Sec 85(1)(b)]
    • Employee files contain the records required by this regulation [RCR Sec 86]
  7. Routine

    8 infractions

    • The facility has a written policy and procedure for obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility. [RCR Sec 85(2)(m)]
    • A short term care plan is developed on admission to guide staff in protecting and promoting the health and safety of the person in care [RCR Sec 80(1); Bill of Rights 1(a)]
      • Short term care plan(s) were not developed.
      • Not all required elements are recorded in the short term care plan.
    • Care plans are developed within 30 days of admission for admissions of 30 days or more. [RCR Sec 81(1); Bill of Rights 1(a)]
    • The care plan(s) contains all items that must be recorded under this regulation [RCR Sec 81(3)]
      • Does not include an assessment of the nature of the risk of falling presented by the person in care.
      • Does not include a fall prevention plan.
      • Does not include a plan for following up on any falls suffered by a person in care.
      • Does not include if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan to prevent the person in care from leaving.
      • Does not include if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan to locate the person in care.
      • Does not include behavioural intervention, if applicable.
      • Does not include if a person in care is released on leave under the Mental Health Act or is admitted to the community care facility under an enactment or court order, any condition or requirement.
      • Does not include an oral health care plan.
      • Does not include a recreation and leisure plan.
    • Care plan(s) is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care or at least once a year [RCR Sec 81(4)(b)]
      • Care plan(s) are not reviewed at least once a year.
    • There is a MSAC with the appropriate membership [RCR Sec 68(1)]
      • MSAC does not include the manager or a person designated by the manager.
      • MSAC does not include the supervising pharmacist appointed under RCR Sec 68(2).
      • When employed the MSAC does not include the health professional responsible for the immediate supervision of health care services.
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
      • Rooms and common areas are not maintained in a good state of repair.
      • Rooms and common areas are not maintained in a safe and clean condition.
    • Employee files contain the records required by this regulation [RCR Sec 86]
      • Does not contain criminal record check results.
      • Lacks a record of character references.
      • Lacks a record of compliance with the Province's immunization and tuberculosis control programs.
      • Lacks record of any performance reviews made under section 40 [continuing monitoring of employees]
      • Lacks record of any attendance at continuing education programs.
  8. Routine

    7 infractions

    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
      • Employees have not been trained in the emergency plan.
    • The care plan(s) contains all items that must be recorded under this regulation [RCR Sec 81(3)]
      • Does not include an assessment of the nature of the risk of falling presented by the person in care.
      • Does not include a fall prevention plan.
      • Does not include a plan for following up on any falls suffered by a person in care.
      • Does not include a nutrition plan that assesses a person in care's nutrition status.
      • Does not include an oral health care plan.
      • Does not include a recreation and leisure plan.
    • For facilities over 24 persons in care, the nutrition plan is developed and reviewed on a regular basis with a dietitian. [RCR Sec 83(2),(3)(b)]
      • For facilities over 24 persons in care, the nutrition care plan is not developed with a dietitian.
      • For facilities over 24 persons in care, the nutrition care plan is not reviewed with a dietitian regularly.
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]
      • Rooms and common areas are not maintained in a safe and clean condition.
    • The written policies and procedures are reviewed and revised if necessary at least once each year [RCR Sec 85(1)(b)]
    • Employee files contain the records required by this regulation [RCR Sec 86]
      • Does not contain criminal record check results.
      • Lacks a record of character references.
      • Lacks a record of compliance with the Province's immunization and tuberculosis control programs.
      • Lacks record of any performance reviews made under section 40 [continuing monitoring of employees]
      • Lacks record of any attendance at continuing education programs.
    • A qualified employee is designated to organize and supervise physical, social and recreational activities and has sufficient time to carry out activities [RCR Sec (45)(a)(b)]
  9. Routine

    8 infractions

    • Prior to or on admission persons in care are informed of the facility's policies respecting expressing concerns, making complaints and resolving disputes [RCR Sec 48(1)(b)]
    • Prior to and or on admission persons in care are informed on how to express concerns or make complaints to the medical health officer or the Patient Care Quality Office [RCR Sec 48(1)(c); Bill of Rights 3(e)]
      • Persons in care are not advised on how to express concerns or make complaints to the medical health officer.
      • Persons in care are not advised on how to express concerns or make complaints under the Patient Care Quality Review Board Act.
    • Persons in care are able to have family or a representative receive advice on admission and, make complaints [RCR Sec 48(1)(c); Bill of Rights 3(f)]
    • There is an annual opportunity for persons in care and family members to establish and participate in a council or similar organization to represent their interests [RCR Sec 59; Bill of Rights 3(b)]
      • Persons in care and family members are not provided with the opportunity to establish a council or similar organization.
    • Persons in care are able to have family or a representative participate on the resident or family council on their own behalf. [RCR Sec. 59; Bill of Rights 3(c)]
    • The most recent routine inspection record is displayed in a prominent place. [RCR Sec. 11(1) (b), (2); Bill of Rights 4(b)]
    • There is on display in a prominent place notice that electronic surveillance is being used [RCR Sec 19(3)]
    • Rooms and common areas are well ventilated, in a good state of repair, safe and clean condition [RCR Sec 22(1)]

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