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)
Routine
November 24, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(c)
Description: A licensee must ensure that all rooms and common areas are maintained in a safe and clean condition.
Corrective Actions Required: Ensure all rooms and common areas are maintained in a safe and clean condition.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 24, 2023
Observations: Licensing toured the facility and audited four person in care's bedrooms. One person in care's bathroom was covered in feces and urine. One person in care's bedroom had significant dirt stains on the floor.
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 a criminal record check has been obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 24, 2023
Observations: This item has been carried forward from Routine inspection AD755A57-B466-4FD7-9807-4C564AD510CF dated November 10, 2022. Licensing was unable to audit staff files on this date.
3010 - RCR 37(1)(b)
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: character references in respect of the person
Corrective Actions Required: Ensure character references have been obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 24, 2023
Observations: This item has been carried forward from Routine inspection AD755A57-B466-4FD7-9807-4C564AD510CF dated November 10, 2022. Licensing was unable to audit staff files on this date.
3010 - RCR 37(1)(c)
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 record of the person’s work history
Corrective Actions Required: Ensure a record of work history is kept for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 24, 2023
Observations: This item has been carried forward from Routine inspection AD755A57-B466-4FD7-9807-4C564AD510CF dated November 10, 2022. Licensing was unable to audit staff files on this date.
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 all employees have complied 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: December 24, 2023
Observations: This item has been carried forward from Routine inspection AD755A57-B466-4FD7-9807-4C564AD510CF dated November 10, 2022. Licensing was unable to audit staff files on this date.
3010 - RCR 43(1)(a)
Description: A licensee must ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,
Corrective Actions Required: Ensure persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 24, 2023
Observations: This item has been carried forward from Routine inspection AD755A57-B466-4FD7-9807-4C564AD510CF dated November 10, 2022. Licensing was unable to audit staff files on this date.
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: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 24, 2023
Observations: Licensing audited the medication administration record of four person in care. All four person's in care had a medication that was not signed or coded for on multiple dates in November 2023.
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 each person in care is weighed at least once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 24, 2023
Observations: Licensing audited the charts of three person in care. One person in care was missing a record of weights for April, May, and October 2023.