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, 2025
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 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 29, 2025
Observations: This contravention has been brought forward from Routine Inspection dated Aug 2, 2024. Licensing toured the facility and observed multiple areas that had chipped paints and wall damage.
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 medication 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: August 29, 2025
Observations: Licensing toured the facility and observed medication in one person in care's bedroom closet that was not secured.
3010 - RCR 37(1)(b)
Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: character references in respect of the person
Corrective Actions Required: Ensure that all staff have a record of character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 19, 2025
Observations: Licensing audited four staff files and one staff file was missing character references.
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 of the policies are reviewed and revised if necessary once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2025
Observations: Licensing audited the policies and procedures. Six policies were last reviewed in 2023.
3070 - RCR 78(1)(a)
Description: A licensee must keep, for each person in care, a record showing the following information: name, sex, date of birth, medical insurance plan number and immunization status
Corrective Actions Required: Ensure all persons in care have a record of immunization status on admission.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 19, 2025
Observations: Licensing audited two persons in care's records. Both persons in care did not have a record of immunization status.