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)
Routine
January 15, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 29(1)(a)
Description: A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including a safe, secure place in which the person in care may store valuable property
Corrective Actions Required: Ensure that each person in care is provided, at no cost, a safe, secure place in which the person in care may store valuable property.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2026
Observations: Licensing audited the rooms of persons in care. No persons in care appeared to have a safe, secure place in which to store valuable property.
3010 - RCR 43(1)(a)
Description: A licensee must ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,
Corrective Actions Required: Ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2026
Observations: Licensing audited staff files. The Licensee was unable to locate the First Aid certificate's for staff.
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure to keep the criminal records check results for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2026
Observations: Licensing reviewed staff files. The Licensee was unable to locate criminal record check results for staff.
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 to keep the following records in respect of each employee: compliance 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: April 15, 2026
Observations: Licensing audited staff files. The Licensee was unable to produce evidence of Tuberculosis testing or immunization records.
3020 - RCR 85(1)(c)(ii)
Description: A licensee must do all of the following: make all policies and procedures available to a medical health officer on request
Corrective Actions Required: Ensure to make all policies available to a medical health officer on request.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2026
Observations: Licensing requested to see the policy manual however the Licensee was unable to locate the manual at the time of inspection.
3030 - RCR 81(1)
Description: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Corrective Actions Required: Ensure that is a person in care is admitted to a community care facility for more than 30 days, there is a care plan for the person in care made in accordance with this section within 30 days of admission.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 22, 2026
Observations: Licensing reviewed two person in care's care plans. One person in care, who was admitted to the facility in September 2025, did not have a care plan.
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: 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2026
Observations: Licensing audited the care plans of persons in care. The care plans were last reviewed two to five years prior.
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 and advisory committee including a pharmacist is appointed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2026
Observations: Licensing was made aware that there was a new pharmacy used for the facility and the supervising pharmacist was not apart of the medication safety and advisory committee.