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 23, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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 person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 23, 2022
Observations: Licensing inspected the tub room and observed a large container of cleaner on the floor by the tub. The cleaner was normally stored in an unlocked cabinet in the same room.
3000 - 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 all medications in the community care facility are safely/securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 23, 2022
Observations: Licensing inspected rooms of persons in care. Rooms 105 had a tube of Voltaren cream in the bathroom. Room 113 had a bottle of nasal spray in the bathroom.
3010 - 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 to keep records in respect of each employee: (c) 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: July 22, 2022
Observations: Licensing reviewed staff files and one staff file did not have an immunization record.
3060 - DOLSOP (Review Immunization Status)
Description: Immunization status reviewed on admission and regularly there after for each person care
Corrective Actions Required: Ensure clear and up to date immunization records are kept for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 23, 2022
Observations: Licensing audited the care plans of persons in care, and two did not have a record of historical immunizations.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure the care plan includes a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 23, 2022
Observations: Licensing reviewed care plans for persons in care. One person in care did not have an recreation and leisure plan.
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 criminal record check results are obtained for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 23, 2022
Observations: Licensing reviewed staff files and two staff files did not have a current criminal record check.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure character references are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 23, 2022
Observations: Licensing reviewed staff files and one file was missing two character references and another was missing one character reference.
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 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: July 23, 2022
Observations: Licensing reviewed staff files and one staff file had no performance reviews.