Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
Routine
June 3, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3070 - RCR 78(3)(a)
Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,
Corrective Actions Required: Ensure persons in care have consent in writing form the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident of illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 3, 2026
Observations: Licensing reviewed thirteen person in care's files and two files did not have a record of consent to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure that a person in care's care plan incudes an oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 3, 2026
Observations: Licensing reviewed thirteen person in care's care plans and seven did not have oral health care plans.
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required: Ensure that care plans are reviewed and if necessary, modified if there are substantial changes in the circumstances of the persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 3, 2026
Observations: Licensing reviewed thirteen care plans and one care plan had a recent fall risk assessment that indicated high fall risk which was different from the previous low risk assessment. The care plan indicated low risk for falls and did not reflect the high risk assessment.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure that a pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 3, 2026
Observations: Licensing observed the narcotic medications were not packaged and labelled by the pharmacist.
3080 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored.
Corrective Actions Required: Ensure that medications are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 3, 2026
Observations: Licensing observed a medication cart in the hallway unattended and unlocked. There were multiple medication creams in the drawers.