Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)

Complaint Investigation

Inspection Information

Facility Type

Residential Care - 400

Received Date

16-May-2023

Subject

["Neglect","Health and Safety","Physical Plant/Equipment (Includes issues such as cleanliness, state of repair, insufficient quantity of supplies, smoking/vaping etc.)","Fall","Staffing (Includes issues such as suitability, insufficient levels, etc.)"]

Contraventions: A summary of the new contraventions found during the inspections are listed below.

Code

Category/Description

3000 - RCR 15(1) 
 

A licensee must ensure that, if necessary for the health and safety of a person in care, windows are secured in a manner that prevents a person in care from falling from, or exiting through, the window.

Observation: Through the investigation process, Licensing determined that the windows were not secured in a manner that prevented a person in care from falling from, or exiting through, a window.

Corrective action: Ensure that if necessary for the health and safety of a person in care, windows are secured in a manner that prevents a person in care from falling from, or exiting through, the window. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between June 27 and July 21, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: all windows in person in care's rooms had a locking mechanism implemented that could not be opened more than six inches and a review of all windows was conducted to ensure that falling or exiting could not occur. The corrective action plan was reviewed and accepted by Licensing. On July 19, 2023, Licensing conducted a Complaint Inspection Follow Up and ensured all pieces of the corrective action plan were implemented.

3030 - CCALA 7(1)(b)(i) 
 

A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Observation: Through the investigation process, Licensing determined that the facility was not operated in a manner that will promote the health, safety and dignity of persons in care. Specifically, related to the security of the facility.

Corrective action: Ensure that the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between June 27 and July 21, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included, new latches on the patio gate, child-proof knobs, signage, and an alarm sounded when a door opened and had a self-closing mechanism. The corrective action plan was reviewed and accepted by Licensing. On July 19, 2023, Licensing conducted a Complaint Inspection Follow Up and observed that all aspects of the corrective action plan were implemented.

3030 - RCR 52(1)(a)(iii) 
 

A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: neglect

Observation: Through the investigation process, Licensing determined that a person in care was subjected to neglect.

Corrective action: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to neglect. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between June 27 and July 21, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included, an amended residency agreement stating persons in care at risk of eloping were not admitted to the facility and if behaviours arose would be transferred, and environmental restraints included barriers were noted. In addition, all care plans included supervision requirements that stated persons in care were not to be left unsupervised or unattended in common areas. The corrective action plan was reviewed and accepted by Licensing. On July 12, 2023m Licensing received confirmation that all care plans were review and on July 21, 2023 Licensing received a copy of the residency agreement.