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
September 16, 2026
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 that the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 14, 2026
Observations: Licensing observed an unlocked door to the staff room that indicated the door should be locked when not in use. In this area, there had been staff medications and cleaning products that had not been secured that were accessible to persons in care. A staff member was observed entering and exiting the room without locking the door.
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 that all medications in the community care facility are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 14, 2026
Observations: Licensing audited nine person in care rooms and observed medications that were not safely and securely stored in one room.
3010 - RCR 37(1)(a)
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: a criminal record check for the person
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited seven employee files. All contained a current criminal record check.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 37(1)(e)
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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited seven employee files. All files included evidence that the employee had complied with the Province's Tuberculosis Control programs.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited ten person in care files. All files contained evidence that persons admitted to a community care facility comply with the Province's immunization programs.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 87(b)
Description: A licensee must keep a record of the following matters respecting food services menus and menu substitutions
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the food services area. Menu substitution audit forms were available to staff, had been completed by staff and were currently in use.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: