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)
Non-Visit Follow-up
September 27, 2022
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 water temperature does not exceed 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 16, 2022
Observations: Licensing audited two water sources. Both hot water temperatures exceeded 49 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A plan for corrective action is to be submitted to Licensing by September 15, 2022. Full compliance will not be achieved until the plan has been implemented and completed.
3000 - RCR 29(1)(a)
Description: A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including a safe, secure place in which the person in care may store valuable property
Corrective Actions Required: Ensure all persons in care bedroom's have a safe secure place for valuables.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2022
Observations: Licensing observed two person in care bedrooms. Neither bedroom had a safe secure place for valuables.
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 immunization records for persons in care are kept on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2022
Observations: Licensing audited two person in care binders. No immunization records were found for either person in care.
3070 - RCR 49(2)
Description: A licensee must record the height and weight of each person in care on admission.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received a form for the height and weight of person in care upon to be documented upon admission.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 49(2)
Description: A licensee must record the height and weight of each person in care on admission.
Corrective Actions Required: Ensure person in care height and weight is recorded upon admission.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 28, 2022
Observations: Licensing audited two person in care files. There were no documented height or weight for either person in care upon admission.
3070 - RCR 87(b)
Description: A licensee must keep a record of the following matters respecting food services menus and menu substitutions
Corrective Actions Required: Ensure all menu food substitutions are recorded.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2022
Observations: Licensing requested to audit the menu food substitution list. Staff informed Licensing that menu food substitutions were not record.
3080 - 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:
Corrective Actions Taken By Licensee: Licensee purchased two new fire extinguishers to replace the fire extinguishers with expired tags.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3080 - 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 all fire extinguisher are up to date with valid tags.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 28, 2022
Observations: Licensing audited two fire extinguishers. Both fire extinguishers had expired tags.
3080 - RCR 71(a)
Description: A licensee must ensure that employees do not make handwritten changes to the directions for use of a medication on the medication container or package
Corrective Actions Required: Ensure no handwritten changes are made to the directions for use of a medication.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 1, 2022
Observations: Licensing audited the Medication Administration Record (MAR) binder. Two MAR sheets had hand written changes.