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)
Follow-Up
September 29, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3030 - RCR 59.1(3)(b)
Description: A licensee must not do any of the following: interfere with a member of the council's participation on the council, including, subject to section 57(3), by preventing a member from entering the premises to attend a council meeting.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3000 - RCR 17
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:
Corrective Actions Taken By Licensee: Licensing tested the water at two sinks in communal areas accessible to persons in care and two persons in cares rooms, and found no source above 49 degrees Celsius.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 40(1)(a)
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 office under subsection (2) to ensure that the employee 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: November 3, 2025
Observations: Licensing audited 12 staff files and found 10 files missing performance reviews.
3070 - RCR 11(1)(b)
Description: A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility the most recent routine inspection record made under section 9 (1) (d) of the Act.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed the last Routine Inspection posted.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required: Ensure that for each person in care, there is a record showing the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care and Care Facility Act or section 50.1 of this regulation, as applicable.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2025
Observations: Licensing audited six records of persons in care and one was missing consent to admission of care.
3070 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure that the following records in respect of each employee are kept: criminal record check results.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2025
Observations: Licensing audited twelve staff files and found three missing criminal record checks and one which expired in April of 2024.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure that the following records in respect of each employee are kept: character references
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2025
Observations: Licensing audited twelve staff files and observed three files missing character references and another three only having one character reference.
3070 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure that the following records in respect of each employee are kept: compliance with the Province's immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2025
Observations: Licensing audited twelve staff files and found three files missing immunization and tuberculosis records.