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
May 12, 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: Ensure that the facility is operated in a manner that will promote 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: February 20, 2025
Observations: Licensing toured the facility and observed several cleaning agents and chemicals, including bleach, accessible to persons in care. Licensing also toured the outdoor area and observed three buckets of cigarette butts; two of which were open and half-full, and observed hundreds of cigarette butts on the ground and surrounding areas.
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:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed that the downstairs bathroom had all light bulbs replaced, the front porch patio furniture had new cushion covers, the dressers for persons in care and the sink used by a person in care appeared to be in a good state of repair.
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: Ensure that all bathrooms have slip resistant material on the bottom of each bathtub or shower.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2025
Observations: Licensing toured the facility and observed that a bathroom on the lower-level did not have slip resistant material on the bottom of the bathtub.
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 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: February 20, 2025
Observations: Licensing toured the facility and observed a medication in the bedroom of a person in care that was not safely or securely stored.
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.
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the care plans for four persons in care and observed that all persons in care, who were at risk of falling, had a plan to address following-up on any falls suffered.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the care plans and charts for four persons in care, and observed that all persons in care who were determined to be at risk of leaving the community care facility without notification of an employee, had a plan to locate the persons in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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.