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)
Non-Visit Follow-up
March 25, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - CCLR 19(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 first met with the person and obtained all of the following: a criminal record check for the person
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated February 15, 2022, photographs of two staff criminal record checks.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 19(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 first met with the person and obtained all of the following: a criminal record check for the person
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - CCLR 19(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 first met with the person and obtained all of the following: (b) character references in respect of the person
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - CCLR 19(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 first met with the person and obtained all of the following: (b) character references in respect of the person
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by emails, dated January 21 and January 26, 2022, photographs of four staff member's character references.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 19(1)(f)
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 first met with the person and obtained all of the following: evidence that the person has complied with the Province’s immunization and tuberculosis control programs
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - CCLR 19(1)(f)
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 first met with the person and obtained all of the following: evidence that the person has complied with the Province’s immunization and tuberculosis control programs
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated January 21st, 2022, two photograph's of immunization status records for two staff members.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated February 02, 2022, a picture of the facility fire and emergency drill record and Licensing observed a Fire drill recorded for January 2022, indicating a fire drill was practiced in January 2022.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 29(c)
Description: To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated January 21st, 2022, a photograph which provided a record of 21 hours of education, related to children and youth.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 29(c)
Description: To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3020 - CCLR 56(1)(c)
Description: A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment]
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3020 - CCLR 56(1)(c)
Description: A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment]
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated February 02, 2022, a picture of the facility fire and emergency drill record log and Licensing Observed Fire drills recorded for September and November 2021 and January 2022.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 59(b)
Description: In respect of a record referred to in this Division, a licensee must (b) keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by Kiteworks, dated February 11, 2022, A Care plan and 4 immunization records.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 59(b)
Description: In respect of a record referred to in this Division, a licensee must (b) keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations: