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Wallace Road Duplex

250-254 Wallace Rd Kelowna BC V1X 4T1 · Residential Care - Licensing

9 inspections

  1. 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 facility has two refrigerators which are used for person in care's food. It was discussed with the manager that the temperature of each refrigerator is to be monitored and recorded daily; however, a review of these documents indicated that there were no recorded temperature checks for one refrigerator since September 21, 2025. Not monitoring the temperature of refrigerators as set out by policies may increase the risk of illness if food is being stored at unsafe temperatures. Submit to Licensing by October 30, 2025, a plan which details how refrigerator temperature will be monitored as required. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Person in care charts were reviewed and two of the charts were observed to have no height and weight at the time of admission. Not recording this information on admission increases risk to persons in care as there is no baseline to observe if health changes occur. Submit to Licensing by October 30, 2025, a plan which details how the height and weight of each person in care will be recorded on admission. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements. The plan must also detail how this contravention will be brought into compliance. Person in care charts were reviewed and two of the charts were observed to have no photograph of the person in care. A photograph is necessary in case of an emergency where the person may need to be identified, and a photograph distributed in a timely manner. Submit to Licensing by October 30, 2025, a plan which details how photographs will be taken and retained to meet this section of the legislation. The plan must also detail how this contravention will be brought into compliance.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1I - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): In one of the refrigerators, it was noted that there was expired food. There was also food that was unlabeled with no dates. Expired food and food that does not have dates on it may pose a risk to persons in care if the food is ingested as it may cause persons to become ill. Submit to Licensing by October 30, 2025, a plan which details how all food will be safely stored. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 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): Person in care charts were reviewed and one chart showed that no weights have been taken since April 2025. It was discussed that the person in care does not want their weight to be taken; however, there was no documentation in the nutrition plan to indicate why weight was not being taken. Monthly weights not being taken increases risk to persons in care as it may not be evident if a person has had a significant change in weight and this may cause a delay in care being sought. Submit to Licensing by October 30, 2025, a plan which details how persons in care will be weighed monthly. If persons in care refuse, or are unable, to be weighed, submit a plan which details how this will be recorded in the nutrition plan. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R10.3S - Record in the nutrition plan the reason why a person in care has refused or is unable to be weighed and that immediate advice is sought of a health care provider when it appears that a person in care may have experienced a significant change in weight; 83( 5 )(a) (b)
  2. Routine Inspection

    5 infractions

    • 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 observed that self-monitoring is not regularly occurring as per the contraventions noted in this report.
      • 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): The Licensee's system to ensure policies and procedures are created to guide employees was found to be ineffective. During the inspection, it was noted that there was no policy in place to guide staff when renovations occur in the home. It was also noted that there was no policy on the inspection and maintenance of ceiling track lifts. The Licensee's system to ensure facility policies are followed by employees was found to be ineffective. During the inspection, it was noted that the facility utilizes a separate binder for information when a person in care is transferred to the hospital. These binders were reviewed and noted to have out of date information, including weight records, incorrect physician names and outdated care plans. It was noted that there was no system in place to ensure these binders are updated when changes to information or care plans are made.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The Licensee's system to ensure persons in care are weighed monthly was found to be ineffective. During the inspection, two persons in care's charts were reviewed and it was noted that one person in care had not been weighed since May 2024 and the other person in care had not been weighed since August 2024.
      • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee's system to ensure menu substitutions are recorded was found to be ineffective. During the inspection, it was noted that there is a document in place to ensure menu substitutions are recorded; however, this document is not utilized and menu substitutions are not retained.
      • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee's system to ensure facility equipment is maintained was found to be ineffective. During the inspection, it was noted that there is no system in place to ensure that ceiling track lifts are inspected on a regular basis. The manager advised that the ceiling track lifts had been inspected within the last few years; however, there was no documentation to show when or if this had occurred. The Licensee's system to ensure chemical products are secure was found to be ineffective. During the inspection, it was noted that the licensee has a locked area where cleaning agents are stored; however, it was noted that a second cupboard is also utilized for chemical storage and this cupboard was noted to be unlocked.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • 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

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): During the inspection it was observed that neither of the 2 bathrooms in the home have slip resistant material on the bottom of the bathtub.
      • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(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?
      • Observation(s): The Licensee's system to ensure that all policies and procedures are followed by staff was found to be ineffective. During the inspection it was noted that narcotic counts are not routinely being completed as required by the facility policy. One observation noted that 10 out of 13 counts were either not completed at all or only completed by 1 person.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The Licensee's system to ensure person in care records are kept current was found to be ineffective. During the inspection it was noted that a person in care had changed their primary health care provider recently; however, the chart was not reflective of this change.
      • R4.1E - Keep for each person a record showing the name and telephone number of the persons parent or representative, contact person and primary health care provider; 78( 1 )(c)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee's system to ensure that snacks include 2 food groups was found to be ineffective. During the inspection it was noted that the second snack of the day only included 1 food group from Canada's Food Guide.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During the inspection it was observed that there was a security camera outside which records at the front door; however, there was no notice to indicate this. The Licensee's system to ensure that all rooms and common areas are in a safe and clean condition was found to be ineffective. During the inspection multiple areas in the home were found to be in poor condition. Including the flooring in the kitchen and the walls in the bathroom. This was also noted on the previous inspection report.
      • R7.1G - Display a notice in a prominent place if electronic surveillance is being used to transmit or record images of persons in care or members of the public; 19 ( 13 )
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
  4. Routine Inspection

    2 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Person in care weights are not consistently being documented at least once each month as required by section 83(4)(a) of the Residential Care Regulation (RCR). Please ensure a system is in place for maintaining compliance.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): On inspection of the physical facility, it was observed that wear and tear of various areas require attention. These areas include kitchen flooring, kitchen counters, and walls. The facility manager is aware of the required maintenance and has put in a request to have work completed in these areas.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  5. Routine Inspection

    1 infraction

    • R9.2 - Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?
      • Observation(s): There is currently no system in place for the review/consult of medication errors with the supervising pharmacist. There is a system in place for the documentation of medication errors and for the follow up by the manager with the employee who made the error, however these errors are not reviewed with the supervising pharmacist.
      • R9.2A - Appoint a supervising pharmacist to consult with employees respecting medication interactions and other problems related to medication; 68( 2 )(c)
  6. Monitoring

    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): There is currently no policy and procedure in place to guide the staff in outbreak prevention and control as per The Director of Licensing Standards of Practice (DOLSOP). DOLSOP states 1(f) Develop general facility outbreak prevention and control policies as recommended by the Health Authority's Medical Health Officer.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): LO visited the main office to review employee files. LO reviewed three employee files and found the files to be missing character references, immunization screening, and work history.
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1D - Obtain a record of work history for all employed persons; 37( 1 )(c)
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • R4.6 - Are facility records current and complete?
      • Observation(s): UNRESOLVED - There continues to be no process or system in place for the monitoring of food services provided to persons in care. The manager states that the employees who work the night shifts prepare the meals for the next day. The employees eat the prepared meals with the persons in care, and do informal audits of the meal service daily, however there is no record available for LO to review.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
  7. Monitoring

    3 infractions

    • R4.6 - Are facility records current and complete?
      • Observation(s): January 17, 2017 - The facility does not have a system in place to retain records for the monitoring of the food services and nutrition care. LO inquired if the facility had any records for the monitoring of the food services. The employee stated that the facility does informal monitoring, however there is no documentation of this. The facility has had yearly family/resident council meetings and there is an attendance list, however there is no documentation of the items discussed or documented outcomes for the meeting.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
      • R4.6H - Retain records of compliance with family and resident council required in section 59; 89( 2 )(b)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): January 17, 2017 - The facility's system for ensuring compliance with ensuring snacks contain two food groups is ineffective. LO reviewed the menu and found one food group listed for each snack with water or juice.
      • 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): January 17, 2017 - The facility's system to ensure compliance with the safe storage of food is ineffective. LO observed three separate containers in a drawer in the fridge that were unlabelled. The employee was unsure what was in the containers or how old it was. All three items were discarded during the inspection.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  8. Monitoring

    1 infraction

    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Fire extinguishers were due for annual check in May.
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  9. Monitoring

    7 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The PRN treatment creams do not have documented effectiveness.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78(2)(b)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): January 14, 2015 - Staff files not reviewed today as they are located off site at the head office.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (11)
    • 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): November 21, 2013- UNRESOLVED - Unable to locate a policy to guide employees on the release of Residents from the Facility to both authorized and unauthorized individuals.
      • Ensure there are written policies and procedures regarding access to persons in care by persons who are not employees of the community care facility; 85(2)(e)
      • Ensure there are written policies and procedures regarding the release of children, youths and vulnerable adults by authorized persons, including if an authorized person appears to be incapable of providing safe care to the person in care; 85(2)(f)(i)
      • Ensure there are written policies and procedures regarding responding to requests for release of children/youths/vulnerable adults by persons not authorized to do so; 85(2)(f)(ii)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff files not reviewed during inspection as they are located at the head office.
      • Obtain a record of work history for all employed persons; 37(1)(c)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37(1)(e)
      • 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)
      • Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 (1)(a)
      • Ensure employees responsible for the preparation and delivery of food receive ongoing education respecting the preparation and delivery of food, nutrition, and if required, assisted eating techniques; 44 (1)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Unable to locate the admission date, weight and Height in the Resident's' charts
      • Record the height and weight of each person in care on admission; 49 (12)
      • Keep for each person a record showing the date of admission to the facility; 78(1)(b)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Staff files not reviewed during inspection as they are located off site at the head office.
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): August 13, 2013 - UNRESOLVED- Requesting a Health and Safety Plan for the monitoring of water Temperatures.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17