Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required: Ensure that water accessible to persons in care is not heated to more than 49 degrees Celsius.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: July 29, 2025

Observations: Licensing tested the water temperature for two sinks accessible to persons in care. One of the sinks had a water temperature reading of 49.8 degrees Celsius, and the second sink had a water temperature reading of 50.1 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A verbal plan for corrective action was submitted to Licensing on July 29, 2025, by the Manager, who stated they would contact BC Housing to lower the water temperature, staff would monitor the water temperature and ensure it was not too hot prior to the use of the sinks by persons in care. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,

Corrective Actions Required: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: September 30, 2025

Observations: Licensing audited three staff files and observed that two staff did not have up to date performance reviews.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: July 29, 2025

Observations: Licensing audited the Medication Administration Record for two persons in care and observed that both person in care did not have a medication signed or coded for by staff on July 21, 2025, and one person in care had three medications not signed or coded for by staff on July 12, 2025.

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required: Ensure that up to date employee criminal record check results are kept on file.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: August 29, 2025

Observations: Licensing audited three staff files and observed that one staff had criminal record check results which expired March 2025.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: July 29, 2025

Observations: Licensing audited the medications for persons in care and observed that one person in care had two rolls of PRN (as needed) medication that expired in June 2025, and one roll of PRN medication that expired in March 2025.