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)
Complaint
August 8, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 21(d)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a safe and clean condition.
Corrective Actions Required: Ensure that all furniture and equipment for use by person in care are maintained in a safe and clean condition. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 15, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a person in care's wheelchair was to be cleaned weekly, and spot checked as necessary, this task was added to the shift duties list and communicated to staff at a team meeting on May 19, 2026. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 19, 2026
Observations: Regarding intake April 14, 2026. Through the investigation process, Licensing determined that there was no regular cleaning of a person in care's wheelchair.
3010 - 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 to operate the community care facility in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 15, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: care plans were to be reviewed annually with facility staff in conjunction with the HSCL nurse, and person centred care plans were to be reviewed at least annually and as needed. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 24, 2026
Observations: Regarding intake April 14, 2026. Through the investigation process, Licensing determined that staff left non-food items available to a person in care after becoming aware that they may ingest these items.
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required: Ensure that each plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: on May 15, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: care plans were to be reviewed annually with facility staff in conjunction with the HSCL nurse, person centred care plans were to be reviewed at least annually and as needed, and the new procedure for care plans was to be reviewed with the Integrated Services Manager team on May 21, 2026. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 21, 2026
Observations: Regarding intake April 14, 2026. Through the investigation process, Licensing determined that the care plan of a person in care had not addressed ingesting non-food related items.