Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)

Acacia Ty Mawr

Facility Type: Residential Care - 400

Routine

January 27, 2026
Score & Grade: 0 Grade:
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.
Code
Category/Description
3010 - RCR 37(1)(a)
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 criminal record check for the person
Corrective Actions Required: Ensure not to 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 a criminal record check for the employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 27, 2026
Observations: Licensing audited ten employee files. Two employee files contained criminal record checks that expired in September and December of 2025.
3010 - RCR 37(1)(b)
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: character references in respect of the person
Corrective Actions Required: Ensure to 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 character references for the employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 27, 2026
Observations: Licensing audited ten employee files. Two employee files did not contain character references and one employee file had one character reference.
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 officer under subsection (2) to ensure that the employee continues 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: March 27, 2026
Observations: Licensing audited ten employee files. Eight employee files did not have records of a performance review within the last two years.