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)
Follow-Up
July 3, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the facility and did not observe any chemicals accessible to persons in care. Licensing also toured the outdoor area and observed that the cigarette butts appeared to be disposed of properly.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed that all bathrooms had slip resistant material on the bottom of the bathtub.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing toured the facility and did not observe any medications that were not safely and securely stored.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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) to ensure that the employee continues to meet the requirements of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2025
Observations: This contravention was carried over from the Routine Inspection dated May 30, 2024. On this date, Licensing audited three staff files and observed that two staff did not have up-to-date performance reviews.
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure that each employee has a criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2025
Observations: This contravention was carried over from Routine Inspection dated December 9, 2022. On this date, Licensing audited three staff files and observed that all staff did not have up-to-date Criminal Record Check results kept on file.
3010 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure that each employee has records demonstrating compliance with the Province's immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2025
Observations: Licensing audited three staff files and observed that none of the three staff had a record of immunization.
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 admitted to a community care facility comply with the Province's immunization and tuberculosis control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2025
Observations: Licensing audited the care plans and charts for four persons in care and observed that three persons in care did not have a record demonstrating compliance with the Province's tuberculosis control program, and one person in care was missing a record demonstrating compliance with the Province's immunization program.
3090 - RCR 55(1)(a)(i)
Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care
Corrective Actions Required: Ensure that there is an ongoing plan of physical, social, and recreational activities suitable to the needs of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2025
Observations: Licensing audited the facility recreational calendar for February 2025.There was not a full calendar of ongoing planned activities.