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
April 15, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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:
Corrective Actions Taken By Licensee: Licensing audited all person in care's Medication Administration Records (MARs) for April 2026 and observed all medications, including creams and ointments, had been signed and/or coded for by staff.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3030 - 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 six person in care's bedrooms and no cleaning agents were accessible to persons in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure that each person in care is weighed at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 18, 2026
Observations: Licensing audited eight person in care's records. Four person in care's weights were not recorded for multiple months, over the past year.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited four employee files and observed all files included character references in respect of each employee.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3080 - 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 that a community care facility is operated in a manner that promotes the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 17, 2026
Observations: Licensing observed six persons in care, residing in double rooms in room numbers 226, 249 and 222. Review of the facility file indicated there was an approved exemption to Residential Care Regulation, Section 25(2)(a) with the following condition: Specific to bedrooms numbered 201, 206 and 221 only, that was approved February 24, 2026.
3080 - RCR 72(b)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the facility's medication cabinet on the first floor and observed no expired medications.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: