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
August 29, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 that all rooms and common areas are maintained 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: September 12, 2024
Observations: Licensing toured the facility on this date. Two bedrooms had significant dents and scrapes to the walls.
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).
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2024
Observations: Licensing audited 13 employee files. Two employee files did not have a record of performance review, and two had a performance review dated in 2021.
3010 - RCR 44(2)(a)
Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,
Corrective Actions Required: Ensure if there are 50 or more persons in care in a community care facility, that the food services manager is a nutrition manager with the Canadian Society of Nutrition Management.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 29, 2024
Observations: This contravention was carried over from Routine Inspection dated March 14, 2024. On this date the Manager stated the Food Service Manager did not have their designation in the Canadian Society of Nutrition Management.
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 policies are reviewed and, if necessary, revised at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2024
Observations: Licensing audited the policies and procedures on this date. Three policies were last reviewed May 2023.