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
January 22, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required: Ensure that all rooms and common areas are maintained in good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 25, 2025
Observations: This contravention has been carried over from Routine Inspection dated July 11, 2024. On this date, Licensing observed the kitchen cabinets upstairs had been repaired however the kitchen cabinets downstairs had no doors and had exposed plumbing underneath the sink.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that all persons admitted to a community care facility to comply with the provinces immunization and tuberculosis control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 4, 2025
Observations: Licensing audited two persons in cares records. One person in care did not have an immunization record.
3080 - RCR 68(1)(b)
Description: A licensee must appoint a medication safety and advisory committee consisting of at least the following persons: the supervising pharmacist appointed under subsection (2)
Corrective Actions Required: Ensure that a medication safety advisory committee consists of the following persons: the supervising pharmacist appointed under subsection (2);
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 12, 2025
Observations: Licensing spoke to the Manager and was made aware that there was no supervising pharmacist on the medical safety advisory committee.
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:
Corrective Actions Taken By Licensee: Licensing audited four person in care's medications. All medications were current. No expired medications were observed.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: