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
July 19, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(2)
Description: A licensee must ensure that emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency.
Corrective Actions Required: Ensure that emergency exits are not obstructed/secured in a manner to hinder exit.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 19, 2022
Observations: Licensing inspected the rooms of persons in care. Two of the rooms had the emergency exit blocked by personal items.
3020 - RCR 23(3)(a)
Description: A licensee must make a policy respecting all of the following the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises
Corrective Actions Required: Ensure there is a policy respecting all of the following: (a) the engagement by persons in care in restricted activities; other than the consumption of medical cannabis, on the premises.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 19, 2022
Observations: Licensing reviewed the policies and procedures manual. There is no policy regarding the recreational use of cannabis by persons in care.
3050 - RCR 62(2)(b)
Description: A licensee must ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide,
Corrective Actions Required: Ensure the menu provides two nutritious snacks with at least two food groups daily.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 19, 2022
Observations: Licensing reviewed the menu and there was only one daily snack listed.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure employee character references are kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 19, 2022
Observations: Licensing reviewed staff files. Two staff files had no character references.
3070 - RCR 86(d)
Description: A licensee must keep the following records in respect of each employee: a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Corrective Actions Required: Ensure that records are kept of employee performance reviews.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 19, 2022
Observations: Licensing reviewed three staff files. Three staff files did not have a recent performance review.
3080 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure the community care facility is operated in a manner that will promote the health, safety, and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 19, 2022
Observations: Licensing inspected the facility and found a bottle of chemical cleaner in a drawer of the bathroom, and a bottle of hydrogen peroxide in the bathroom.
3080 - RCR 72(b)
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 medications are returned to the pharmacy if expired.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 19, 2022
Observations: Licensing inspected the medication storage and found a box of expired pain patches.