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 6, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 13, 2023
Observations: Licensing tested the hot water in two person in care's bedrooms on the fourth floor. Both of the temperatures read 58 degrees Celsius. Water temperature on the first, second and third floor were in compliance. This is an immediate risk to the health and safety of persons in care. The Manager informed staff on the fourth floor to not use the hot water. The Maintenance Manager stated they were going to adjust the hot water tank on this date and continue testing the hot water daily, as per the previously submitted safety plan to Licensing.
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required: Ensure all rooms and common areas are maintained and 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 6, 2023
Observations: Licensing observed two person in care's bedrooms on the third floor with significant wall damage.
3010 - RCR 40(1)(a)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,
Corrective Actions Required: Ensure that the performance of each employee is reviewed regularly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 6, 2023
Observations: Licensing audited 10 staff files and 7 staff files had performance reviews dated 2021, 2020 and 2019.
3080 - 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: July 6, 2023
Observations: Licensing audited five person in care's bathrooms and observed medicated creams not securely stored in three bathrooms. The Manager stated they were in the process of implementing a caddy storage system to address this area of non-compliance.