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
July 27, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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 the community care facility is operated in a manner that will promote the health, safety, and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 27, 2026
Observations: On today's date, Licensing toured the facility and observed chemicals, including bleach, not safely or securely stored in a bathroom, in a storage area, and in the bedroom of a person in care.
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 maintained 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: August 24, 2026
Observations: Licensing toured the facility and observed there were wardrobes with missing handles or drawers, and there was wall damage in a bedroom of persons in care on the upper level.
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: August 24, 2026
Observations: Licensing toured the facility and observed visible dust and dirt in the bathrooms of persons in care.
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 that a record of the staff's work history is kept on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 27, 2026
Observations: Licensing audited the staff files and records for four staff and observed that one staff did not have a record of their work history kept on file.
3010 - RCR 40(1)(b)
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 demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required: Ensure that the performance of each employee is reviewed both regulalry and as directed by the medical health officer under subsection (2) to ensure that the employee demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 27, 2026
Observations: Licensing audited four staff files and records and observed that one staff did not have a record of a performance review kept on file, and three of four staff did not have a performance review completed within the past year. The Manager stated that performance reviews were to be conducted annually.
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: July 27, 2026
Observations: Licensing audited the electronic Medication Administration Record (eMAR) for July 19 to 26, 2026, and observed that one person in care did not have two medications signed or coded for by staff on July 24, 2026, as per policy.
3010 - 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 criminal record check results are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 27, 2026
Observations: Licensing audited four staff files and records and observed that one staff did not have criminal record check results kept on file.
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 all persons admitted to a community care facility comply 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: July 27, 2026
Observations: Licensing audited the care plans and records for four persons in care and observed that one person in care did not have a record kept of compliance with the Province's tuberculosis control programs.
3070 - RCR 82
Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Corrective Actions Required: Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 27, 2026
Observations: Licensing audited the care plan for a person in care, which indicated that if they were missing and had not returned by the following shift, an Incident Report was to be submitted to Licensing and Police were to be informed. Licensing observed that on June 25, 2026, the person in care was last seen around 8:00 p.m., and did not return for the entirety of the nightshift, and returned back around 7:30 a.m. the following date. This incident was not reported to Licensing per the care plan of the person in care.
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 the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care, specifically following the terms and conditions on the facility licence.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 27, 2026
Observations: This contravention was carried over from the Routine Inspection dated February 9, 2026. On this date, Licensing discussed Condition #3 with the Manager related to Registered Care Aides (RCAs) completing medication administration training. The Manager stated that there was one RCA who had not yet completed all required aspects of the medication training program previously approved by Licensing. The Manager stated that the condition would be met by the next Licensing Routine Follow-Up Inspection.