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

29-Jun-2022

Subject

["Staffing (Includes issues such as suitability, insufficient levels, etc.)","Supervision","Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)"]

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

Code

Category/Description

3030 - CCLR 34(2)(b) 
 

Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

Observation: Through the investigation process, Licensing determined that on multiple occasions staffing ratios were not met for the first 15 minutes of programming.

Corrective action: Ensure that the ratio of employee to children attending a community care facility is no less than that permitted in Schedule E. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 21, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included a staff schedule showing two staff would be scheduled daily and would start their shift 15 to 25 minutes before dismissal. The corrective action plan was reviewed and accepted by Licensing. On October 24, 2022, Licensing received an updated staff schedule showing two staff are scheduled daily, 15-25 minutes before school dismissal.

3030 - CCLR 34(1) 
 

A licensee must ensure that children are adequately supervised by qualified employees in sufficient numbers to meet the needs of each child.

Observation: Through the investigation process, Licensing determined that on June 2, 2022, 13 children were left unattended for 10 minutes at school dismissal.

Corrective action: Ensure that children are adequately supervised by qualified employees in sufficient numbers to meet the needs of the each child. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 21, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included a staff schedule showing two staff would be scheduled daily and would start their shift 15 to 25 minutes before dismissal. The corrective action plan was reviewed and accepted by Licensing. On October 24, 2022, Licensing received an updated staff schedule showing two staff are scheduled daily, 15-25 minutes before school dismissal.

3070 - CCLR 58(2)(a) 
 

The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.

Observation: Through the investigation process, Licensing determined that child with a known medical condition, attended for two weeks without a medical care plan in place.

Corrective action: Ensure to develop the care plan in consultation, with a parent of the child requiring extra support and any person requested by the parent. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 21, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included a staff meeting being held and email reminders sent to all staff regarding the facility medication policy and medical care plan processes. The corrective action plan was reviewed and accepted by Licensing. Licensing received a copy of the completed care plan for the child in care, as well as evidence of the email sent to all staff on November 24, 2022 and minutes from the January 9, 2023, staff meeting.