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
June 4, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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:
Corrective Actions Taken By Licensee: Licensing toured the facility. All medications were safely and securely stored.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 1, 2026
Observations: Licensing audited the electronic Medication Administration Record (eMAR) for persons in care and observed that one person in care did not have a medication signed or coded for by staff on March 12, 2026, and another person in care did not have a medication signed or coded for by staff on March 19, 2026 as required by policy.
3020 - RCR 85(1)(b)
Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year
Corrective Actions Required: Ensure that all policies and procedures at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 1, 2026
Observations: Licensing audited the policies and procedures for the facility and observed that all required policies had not been reviewed in the past year.
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the care plans and records for 26 persons in care and observed that all persons in care had a fall prevention plan which addressed a plan for following up on any falls suffered.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the care plans and records for 26 persons in care and observed that all care plans had been reviewed within the past year.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the facility and audited medications and did not observe any medications that were not packaged by a pharmacist.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: