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
February 5, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed a light fixture in one person in care's bedroom that had a protective cover replaced. Licensing observed a new smoke detector had been installed on the second floor.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - RCR 31(b)
Description: A licensee, other than a licensee who provides a type of care described as Long Term Care, must provide one bathtub or shower for every 4 persons in care.
Corrective Actions Required: Ensure that a licensee, other than a licensee who provides a type of care described as Long Term Care, provided one bathtub or shower for ever 4 persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 5, 2025
Observations: Licensing observed two locked bathrooms, with bathing facilities, for persons in care due to renovations occurring, with a sign "out of order" posted on the doors. The facility had two bathing facilities that were accessible to persons in care. Inside each bathing facility, was one bathtub and one shower. The total capacity for the facility was 24 persons in care. There was one double room downstairs that had a shower accessible to the two persons in care residing in that bedroom.
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 2, 2024
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:
Corrective Actions Taken By Licensee: Licensing audited three person in care's medications and Medication Administration Records (MARs) dated February 2025, and all were 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:
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:
Corrective Actions Taken By Licensee: Licensing audited three person in care's weight records dated October, November, December 2024, and January 2025. All persons in care had been weighed at least once a month.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: