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
October 24, 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 Degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 31, 2025
Observations: Licensing tested the hot water temperature in the downstairs bathroom which read 51 Degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Manager stated they sent an email to BCHousing on this date, to come on site and adjust the water temperature. Full compliance will not be achieved until the plan has been implemented and completed.
3000 - RCR 35(2)(a)
Description: A licensee must ensure that laundry facilities if used by persons in care, have a slip resistant floor surface
Corrective Actions Required: Ensure that laundry facilities, if used by persons in care, had a slip resistant floor surface.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 24, 2025
Observations: Licensing observed the laundry facility, used by persons in care, had a mat that was not slip resistant.
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: November 24, 2025
Observations: Licensing audited two person in care's Medication Administration Records (MARs) and observed one person in care's MAR had three PRN (as needed) medications administered, with the results documented with a question mark. The PRN Medication Policy and Procedure indicated staff were to monitor a person in care after administering a PRN and document the effectiveness results.