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 28, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 28, 2026
Observations: Licensing audited 15 staff files. Seven staff files did not contain a performance review.
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 all staff files contain criminal record checks.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 2, 2026
Observations: Licensing audited 15 staff files. Three staff files did not contain criminal record check results.
3030 - RCR 49(3)
Description: A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Corrective Actions Required: Ensure each person in care is assessed on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 28, 2026
Observations: Licensing audited four person in care files. Three files did not contain an assessment for elopement risk.
3070 - RCR 49(2)
Description: A licensee must record the height and weight of each person in care on admission.
Corrective Actions Required: Ensure that upon admission, a record for each person in care's height and weight is completed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 28, 2026
Observations: Licensing audited four person in care files. There was no record of heights for persons in care on admission.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure all person in care's care plans contain a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 28, 2026
Observations: Licensing audited four person in care's care plans. All four care plans did not contain a recreation and leisure plan.