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
August 12, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: Ensure that all rooms and common areas are in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 12, 2025
Observations: Licensing toured six person in care's bedrooms and bathrooms, and observed the wallpaper, located in one person in care's bathroom had significant peeling.
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 that 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: September 12, 2025
Observations: Licensing toured six person in care's bedrooms and observed two bedrooms had significant dirt and staining on the floors.
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: October 12, 2025
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.
3070 - RCR 11(1)(b)
Description: A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility the most recent routine inspection record made under section 9 (1) (d) of the Act.
Corrective Actions Required: Ensure that the most recent Routine Inspection is posted in a prominent place, in the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 12, 2025
Observations: Licensing toured the facility, and observed the most recent Routine Inspection was not posted in a prominent place, in the community care facility.
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required: Ensure that each person in care has a record of consent for admission for the person in care to be admitted, or to continue to be accommodated in the community care facility, in accordance with the Health Care (Consent) and Care Facility (Admission) Act.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 12, 2025
Observations: Licensing audited three person in care's records and one person in care did not have consent to be admitted, or to continue to be accommodated in the community care facility, in accordance with the Health Care (Consent) and Care Facility (Admission) Act.