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
August 17, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received a maintenance request form which indicated that the second bathroom faucet was reinforced and secured.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required: Ensure that all furniture and equipment is maintained in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 24, 2022
Observations: Licensing toured the facility and observed the sink tap in the bathroom was not secured.
3010 - RCR 37(1)(b)
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 obtained all of the following: character references in respect of the person
Corrective Actions Required: Ensure that character references are kept in respect of each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 24, 2022
Observations: Licensing audited four staff files and observed one staff file did not have a character references kept in respect of the employee.
3010 - RCR 37(1)(b)
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 obtained all of the following: character references in respect of the person
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received staff's character references check document.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 that records are kept in respect of each employee: 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 24, 2022
Observations: Licensing audited four staff files and observed one staff file did not have a record kept to indicate the employee complied with the Province's tuberculosis program.
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:
Corrective Actions Taken By Licensee: Licensing received staff's tuberculosis test records which indicated a negative result.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required: Ensure that policies are implemented by employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 24, 2022
Observations: Licensing audited four staff files and observed one staff had a performance review dated June 2020. The Manager stated performance reviews were to be conducted annually as per the policy.
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received staff's current performance review.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: