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
November 28, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(c)
Description: A licensee must ensure that all rooms and common areas are maintained in a safe and clean condition.
Corrective Actions Required: Ensure that all rooms and common areas are maintained in a safe and clean condition.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 29, 2025
Observations: Licensing toured ten person in care's bedrooms and bathrooms, and observed significant scratch marks located on the floor of one person in care's bedroom.
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 all policies and procedures are reviewed at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 29, 2025
Observations: Licensing audited the facility's policy and procedure manual. The cannabis use policy was last reviewed in 2022 and reportable incidents policy was last reviewed in 2023.
3070 - RCR 81(3)(e)(ii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for preventing the person in care from falling
Corrective Actions Required: Ensure that in the case of a person in care who may be prone to falling, there is a fall prevention plan that addresses a plan to prevent the person in care from falling.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 29, 2025
Observations: Licensing audited six person in care's care plans. One person in care, identified as a high risk for falling, did not have a fall prevention plan that addressed preventing the person in care from falling.
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care
Corrective Actions Required: Ensure that in the case of a person in care, who may be prone to falling, there is a fall prevention plan that addresses a plan for following up on any falls suffered by a person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 29, 2025
Observations: Licensing audited six person in care's care plans. Three persons in care, identified as being prone to falling, did not have a plan for following up on any falls suffered.
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure that each person in care is weighed at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 26, 2026
Observations: Licensing audited six person in care's weight records. Five persons in care did not have a weight record for at least once month in 2025.
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: December 29, 2025
Observations: Licensing toured ten person in care's bedrooms and bathrooms, and observed one person in care's medicated cream, located on the bathroom counter.