Willowview

1808 30 St Vernon BC V1T 5C5 · Residential Care - Licensing

8 inspections

1. Routine InspectionOct 23, 2025

   0 infractions

2. Routine InspectionAug 15, 2024

   2 infractions

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): The system to ensure immediate notification to Licensing is ineffective as a review of incident reports identified multiple late submissions. A review of the reportable and non-reportable incident binder identified reportable incidents that were recorded as non-reportable. The reportable incident log sheet was also identified as missing reportable incidents that were submitted to Licensing. Overall, the binder was disorganized and contained information of reportable incidents from the Assisted living Regulation fact sheet. This was also a contravention on the last routine inspection.
     • 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)
     • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): The system to ensure that care plans are complete is ineffective, they did not contain all of the required components of a Care Plan. This was also a contravention on the last routine inspection. The system to ensure monthly weights are recorded is ineffective, it was identified that a monthly weight was not recorded and that the system for recording was disorganized.
     • R4.1S - Ensure a short term care plan developed on admission includes anything that must be recorded in a care plan; 80 ( 2 )
     • 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)
3. Routine InspectionFeb 29, 2024

   4 infractions

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): The system to ensure records of minor and reportable incidents is maintained is ineffective. A review of the minor and reportable incidents binder identified missing reports as well as incorrectly identified reports.
     • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(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): The system to ensure employees are completing checklists as per policy is ineffective. Day, evening, weekly and monthly chore checklists were observed to not have been completed as per policy.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system to ensure that persons in care have access at all times to an employee certified in First Aid and CPR is ineffective. It was observed that several employees certificates are not currently valid. The system to ensure that employees that prepare or handle food are certified is ineffective. It was observed that several employees are currently not certified.
     • R3.1O - 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)
     • R3.1Q - 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)
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): The system to ensure that short-term Care Plans contain all the necessary components is ineffective. A review of Care Plans identified missing components such as a Nutritional plan or Recreation plan.
     • R4.1P - Ensure a short term care plan developed on admission includes anything that must be recorded in a care plan; 80 ( 2 )
4. Routine InspectionAug 28, 2023

   6 infractions

   • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
     • Observation(s): The system to provide ongoing program of activities is ineffective, there are no planned program of activities.
     • R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
   • 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): Emergency Preparedness plans are ineffective as they did not contain plans for the evacuation of persons in care other than to meet at a marshalling point outside the facility. There was no plan setting out how persons in care will continue to be cared for in the event of an emergency. A review of the ‘Daily Safety Huddle Notes’ indicated they are sporadically completed. The last entry was on 11th August, 2023. According to the facility Team Lead these are supposed to be completed daily as per policy.
     • 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)
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system for Performance reviews is ineffective. Facility Team Lead was unable to produce or know when they were last completed. As per the last Medication Safety and Advisory Committee meeting minutes, “PRN’s need to indicate if effective and if not, some explanation needed.” A review of the MAR indicated several PRN’s effectiveness were not charted.
     • 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)
     • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): The system to ensure that each person in care is weighed at least once per month is ineffective, there were no records.
     • 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): A review of the weekly menu only indicated one snack per day, which did not have at least two food groups.
     • 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): Kitchen cupboards and draws were noted to still be in a state of disrepair, falling apart or broken. This was a contravention on the last inspection. Facility manager confirms that this was reported to plant maintenance but no date provided for completion to come into compliance. A bottle of peroxide was noted to be with laundry detergent which was accessible to persons in care in an unlocked cupboard in the laundry room.
     • 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)
5. Routine InspectionFeb 15, 2023

   7 infractions

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): The system to keep records for minor incidents is in effective, there were no records.
     • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): The system for notifying Licensing of manager changes is ineffective, current manager has been in place since Nov 2022 without notification. It was noted that there was no posted inspection report. The system for self-monitoring was ineffective as noted by the number of contraventions identified in this report, as well as during the inspection, auditing processes were not identified.
     • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
     • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
     • 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 system to ensure persons in care or their representative that would like to express concerns or make complaints to Licensing is ineffective. The system to review and if necessary revise the policies and procedures at least once each year is ineffective, the policies and procedures produced for inspection were dated 2008.
     • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
     • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system to ensure that managers and employees receive the training and orientation of policies & procedures and the Community Care and Assisted Living Act and the Residential Care Regulation is ineffective.
     • R3.1L - Ensure employees have the necessary training and experience or demonstrate the necessary competence to carry out duties; 40 ( 3 )
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): There was no consent in writing from a person in care or a representative of the person in care to call a MRP or ambulance in case of an accident or illness. The system to ensure that care plans are complete is ineffective, they did not contain all of the requirements of a Care Plan.
     • R4.1I - 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)
     • R4.1P - Ensure a short term care plan developed on admission includes anything that must be recorded in a care plan; 80 ( 2 )
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Kitchen cupboards and draws were noted to be in a state of disrepair, falling apart or broken. Outside patio leading to main door is a potential tripping hazard.
     • 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)
   • R9.1 - Are medications stored, handled, and administered appropriately?
     • Observation(s): The facility has no medication safety and advisory committee.
     • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
6. Routine InspectionOct 16, 2019

   1 infraction

   • R4.6 - Are facility records current and complete?
     • Observation(s): October 16, 2019 The Licensee has a system in place for documenting menu substitutions for one week, however there was not a system in place to retain a record of menu substitutions. The manager began putting a system into place immediately to ensure that a record of the menu substitutions is retained.
     • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
7. MonitoringMar 28, 2017

   0 infractions

8. MonitoringFeb 17, 2015

   3 infractions

   • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
     • Observation(s): The manager has used the long term care tuberculosis screening tool as a start for screening of the staff for tuberculosis. The manager will be following up with infection control in regards to the necessary tuberculosis testing and results that is required to be on file for the staff.
     • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (1)
   • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): There are no staff records on site containing any criminal record checks, character references, work history, copies of diplomas, certificates or other evidence of training, immunization screening, tuberculosis results or performance evaluations to meet section 37 of the Regulation. A copy of the staffing template devised by Licensing will be forwarded to the manager to complete and have on site for Licensing to review during inspections. All performance evaluations are to be completed by Aug. 18, 2015
     • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
     • Obtain character references for all employed persons; 37(1)(b)
     • Obtain a record of work history for all employed persons; 37(1)(c)
     • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37(1)(d)
     • 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)
   • 4.4 Are records kept on each employee with the necessary requirements?
     • Observation(s): As per above - no staff records are kept on site other than first aid certification. A copy of the staffing template devised by Licensing will be forwarded to the manager to complete and have on site for Licensing to review during inspections.
     • Keep employee criminal record check results; 86(a)
     • Keep employee character references; 86(b)
     • 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)