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
October 30, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited six persons in care's bathrooms water temperature and all were not heated to more than 49 degrees Celsius.
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: Ensure that all medications are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 9, 2025
Observations: Licensing observed the medication cart in the hallway unlocked and unattended by staff.
3010 - RCR 37(1)(e)
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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure staff have complied with the provinces immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 30, 2025
Observations: Licensing reviewed nine staff files and two staff files did not have copy of tuberculosis results.
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 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: October 30, 2025
Observations: Licensing reviewed nine staff files and three staff files did not have a regular performance review completed.
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required: Ensure all staff have records of character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 30, 2025
Observations: Licensing reviewed nine staff files and three staff files did not have records of character references.
3030 - RCR 63(3)(c)(iii)
Description: A licensee must ensure that meals are provided by ongoing room tray service, if approved by the person in care’s medical practitioner or nurse practitioner
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited eleven person in care's files and observed the medical practitioner approval for ongoing room tray service for all eleven persons in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: