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 3, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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: March 3, 2026
Observations: Licensing toured the facility and observed medicated creams that were not securely stored in a person in care's room.
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 staff 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: March 3, 2026
Observations: Licensing audited the electronic Medication Administration Record (eMAR) and observed that there were three medications not signed or coded for by staff on February 28, 2026, as required by policy.
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required: Ensure character references are kept for each staff.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 3, 2026
Observations: Licesning audited six staff files and records and observed that three of the six staff were missing character references.
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required: Ensure that policies are implemented by staff.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 3, 2026
Observations: Licensing audited six staff files and records and observed that three staff did not have performance reviews completed within the past year, as per policy.
3070 - RCR 80(1)
Description: On admitting a person in care to a community care facility, a licensee must ensure that a short term care plan is developed that will guide caregivers in protecting and promoting the health and safety of the person in care
Corrective Actions Required: Ensure that a short term care plan is developed that will guide caregivers in protecting and promoting the health and safety of the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 3, 2026
Observations: Licensing audited the care plans and records for four persons in care, and observed that one person in care, who was admitted on February 26, 2026, did not have a short term care plan developed.
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 each person in care has a fall prevention plan which 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: March 6, 2026
Observations: Licensing audited the care plans and records for four persons in care and observed that the care plans for two persons in care did not contain a plan for following up on any falls suffered by a person in care.
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required: Ensure that if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan is in place to locate the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 6, 2026
Observations: Licensing audited four care plans and records for persons in care and observed that a person in care who was determined to be at risk of leaving the community care facility without notification of an employee, did not have a plan to locate them if they left the facility without notification.