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
September 22, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2025
Observations: Licensing tested the hot water at two sinks in communal areas assessable to persons in care. The water temperature was 49.7° and 52.2° Celsius. The Manager submitted a hot water correction plan and will contact maintenance to adjust water temperatures. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. Full compliance will not be achieved until the plan has been implemented and completed.
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 office under subsection (2) to ensure that the employee 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: November 3, 2025
Observations: Licensing audited 12 staff files and found 10 files missing performance reviews.
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 other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, displays 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 13, 2025
Observations: Licensing observed a posted follow up inspection dated May 1, 2024 which was not the most recent Routine Inspection.
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 for each person in care, there is a record showing 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 and Care Facility Act or section 50.1 of this regulation, as applicable.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2025
Observations: Licensing audited six records of persons in care and one was missing consent to admission of care.
3070 - 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 the following records in respect of each employee are kept: criminal record check results.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2025
Observations: Licensing audited twelve staff files and found three missing criminal record checks and one which expired in April of 2024.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure that the following records in respect of each employee are kept: character references
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2025
Observations: Licensing audited twelve staff files and observed three files missing character references and another three only having one character reference.
3070 - 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 the following records in respect of each employee are kept: 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: November 3, 2025
Observations: Licensing audited twelve staff files and found three files missing immunization and tuberculosis records.