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)
Non-Visit Follow-up
August 31, 2022
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: Ensure all cleaning agents, chemical products and hazardous materials are kept in a safe and secure location.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 30, 2022
Observations: Licensing observed two unsecured areas (hallway closet and kitchen cabinet) that contained cleaning agents, chemical products and hazardous materials.
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 received an email with photographs showing a lock on the chemical store closet.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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: Ensure that water accessible to persons in care does not exceed 49 degrees Celsius.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 12, 2022
Observations: Licensing audited water from one bathroom and one kitchen sink. Both water temperatures exceeded 49 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A plan for corrective action was discussed with the Manager at the time of the Routine Inspection. Maintenance was to attend to the water temperature immediately. Full compliance will not be achieved until the plan has been implemented and completed.
3000 - RCR 35(2)(a)
Description: A licensee must ensure that laundry facilities if used by persons in care, have a slip resistant floor surface
Corrective Actions Required: Ensure that a laundry room used by persons in care has a slip resistant floor surface.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing observed a laundry room used by persons in care that did not have a slip resistant floor surface.
3010 - RCR 37(1)(a)
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: a criminal record check for the person
Corrective Actions Required: Ensure all employees have a current criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing audited three staff files. One file did not have a current criminal record check.
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 all employees have current performance evaluations.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 29, 2022
Observations: Licensing audited three staff files. All three staff files were missing current performance evaluations.
3070 - RCR 77(2)(c)
Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received an email with eight reportable incidents attached.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 77(2)(c)
Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Corrective Actions Required: Ensure that if a person in care is involved in a reportable incident, the Licensing Program is immediately notified.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing audited an internal facility incident report binder. Licensing observed eight reportable incidents between January 24, 2022 and April 17, 2022 that were not reported to Licensing