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
March 25, 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 a Licensee provides, 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 27, 2026
Observations: Licensing audited three person in care bedrooms. Three person in care did not have a safe, secure place in which they may store valuable property.
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 27, 2026
Observations: Licensing audited three person in care Medication Administration Records (MARs). Three person in care MARs did not have a record of the outcome of an administered as needed (PRN) medication as required by policy.
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 to review and if necessary, revise policies and procedures at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 27, 2026
Observations: Licensing audited the policies and procedures binder. Policies and procedures had not been reviewed within the last year.
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 that upon admission, there is an assessment of the person in care to determine if they are at risk for leaving a 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 27, 2026
Observations: Licensing audited two person in cares records. Two persons in care did not have an assessment on admission that determined the risk that the person in care may leave the community care facility without notification of an employee.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that all persons in care admitted to a community care facility comply with the Province's immunization control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 27, 2026
Observations: Licensing audited two person in care records. Two persons in care did not have documentation demonstrating compliance with the Province's immunization control programs.