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)
Non-Visit Follow-up
March 11, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - CCLR 19(1)(a)
Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: a criminal record check for the person
Corrective Actions Required:
Corrective Actions Taken By Licensee: On December 4, 2024 and March 10, 2025, Licensing received staff renewed CRC copies.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required: Ensure that each employee practices implementing the fire drill system at least once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 7, 2025
Observations: Licensing observed the fire drill log was incomplete. Manager stated the drill had not been completed since the summer.
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required: Ensure that each employee practices implementing the emergency plan at least once a year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 7, 2025
Observations: Licensing observed the annual emergency plan drill was not logged. Manager stated the drill had not been completed.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure for a log is kept of all inspections, maintenance and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 7, 2025
Observations: Licensing observed inspections, maintenance and repairs log was incomplete. Manager and staff stated the inspections were completed, however not logged.