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
July 15, 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: Ensure a person is not employed 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 a criminal record check for the person.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited five staff files of which three were missing a CRC.
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: Ensure 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 character references in respect of the person.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited five staff files of which one was missing character references.
3010 - CCLR 19(1)(d)
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: copies of any diplomas, certificates or other evidence of the person’s training and skills
Corrective Actions Required: Ensure a person is not employed 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 copies of any diplomas, certificates or other evidence of the person's training and skills.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited five staff files of which one was missing evidence of diplomas/certificates/evidence of training/skills for employees.
3010 - CCLR 19(4)(a)
Description: A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry
Corrective Actions Required: Ensure a person is not employed in a community care facility as an educator or an assistant unless it has been verified by the licensee using a system established and maintained by the director of the early childhood educator registry.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited five staff files of which three Educator Assistant certificates had not been verified.
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: Ensure current records respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing observed that the fire drill in the green room had last been documented on May 4, 2021. The emergency plan had last been documented October 2021 in the green room and March 2020 in the red room.
3070 - CCLR 57(2)(a)
Description: A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.
Corrective Actions Required: Ensure for each child, a record showing the following information:
(a)name, sex, date of birth, medical insurance plan number and immunization status;
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited six of 43 children's file of which one was missing immunization status.
3070 - CCLR 58(2)(b)
Description: The licensee must review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required: Ensure the development of the care plan in consultation, and review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited three care plans of which two were indicated that they had not been reviewed within the last year.