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

Complaint Investigation

Inspection Information

Facility Type

Child Care - 300

Received Date

23-Sep-2024

Subject

["Health and Hygiene","Neglect","Policies (Includes issues such as not following, insufficient information or policy missing)"]

Contraventions: A summary of the new contraventions found during the inspections are listed below.

Code

Category/Description

3020 - CCALA 7(1)(b)(i) 
 

A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Observation: Through the investigation process, Licensing determined that Licensee did not demonstrate the skills and abilities to carry out the duties as assigned. Specifically, not following diapering instructions provided by parents and products supplied to the Licensee were not used for the children for whom they were intended.

Corrective action: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care, specifically regarding suitability of the Licensee. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On October 28, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: use a checklist to track each diaper change noting any unusual signs, if any unusual signs was noticed parents would be informed. Each child would have a labelled bin for their own diapers, wipes and changing pads. The corrective action plan was reviewed and accepted by Licensing.

To be corrected by: 10-Feb-2025

3060 - CCLR 46(1) 
 

A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.

Observation: Through the investigation process, Licensing determined that a program to instruct children in and to practice rules of health and hygiene was not established by the Licensee. Specifically, there were no handwashing practices after diapering. Licensing observed the Licensee washed her hands without soap and a child was not washed hands after a diaper change.

Corrective action: Ensure to establish a program to instruct children in and to practice rules of health and hygiene such as appropriate handwashing practices. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On October 28, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Daily cleaning and organizing the changing room, disinfecting the changing mats with bleach solution after each diaper change, washing children's hands with soap, and disposing soiled diapers in a trash bin to keep the area clean. The corrective action plan was reviewed and accepted by Licensing. On October 29, 2024, Licensing received a copy of an updated "Parent Handbook" that included a "Hygiene Promotion" policy via email.

3080 - CCALA 7(1)(b)(i) 
 

A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Observation: Regarding intake March 7, 2025. Through the investigation process, Licensing determined that there were eight children in care and it exceeded maximum allowed capacity of seven children for a Family Child Care program.

Corrective action: Ensure to operate the community care facility in a manner that will promote the health, safety and dignity of persons in care, specifically, not exceeding maximum capacity. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 29, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The Licensee would correct, print and maintain daily attendance records to ensure not exceeding capacity. Each child would have a separate space on the sheet. On April 29, 2025, Licensing received an email with attendance records since March 15, 2025, confirming that all children were listed and that capacity was not exceeded. The corrective action plan was reviewed and accepted by Licensing.

To be corrected by: 08-May-2025

3060 - CCALA 7(1)(b)(i) 
 

A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Observation: Through the investigation process, Licensing determined that the Licensee did not demonstrate the skills and abilities to carry out the duties as assigned. Specifically, when the Licensee did not follow her policies related to hygiene when not washing children's hands after a diaper change.

Corrective action: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care, specifically implementation of policies. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On October 28, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: After each diaper change children will be washed their hands with soap. The "Parent Handbook" was updated to ensure the policies required by Licensing were discussed with parents. The corrective action plan was reviewed and accepted by Licensing. On October 29, 2024, Licensing received a copy of the "Parent Handbook" via email.

To be corrected by: 10-Feb-2025

3080 - CCALA 7(1)(b)(i) 
 

A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Observation: Regarding intake March 7, 2025. Through the investigation process, Licensing determined that the Licensee did not follow the approved off-site plan, as children were not taken to Woodland Creek Park. Instead, children were playing at the daycare's main entrance which did not meet the definition of a backyard.

Corrective action: Ensure to operate the community care facility in a manner that will promote the health, safety and dignity of persons in care, specifically, following an approved off-site plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 29, 2025, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The Licensee would take children to the park daily, rain or shine for a full hour and would keep a record on a checklist. On April 29, 2025, Licensing received an email with records showing the dates and times children had been to the park since March 15, 2025. The corrective action plan was reviewed and accepted by Licensing.

To be corrected by: 08-May-2025