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)
Follow-Up
August 8, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 17
Description: A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child
Corrective Actions Required: Ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing observed no plug covers on one plug in the portable and one plug in room 9.
3000 - CCLR 17
Description: A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed plug covers on outlets accessible to children.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - SPS DOLSOP (Entanglement)
Description: Equipment is free of entanglement hazards in areas of uncontrolled motion. (Something around the child’s neck becomes caught on equipment)
Use Entanglement test device
Corrective Actions Required: Ensure equipment is free of entanglement hazards in areas of uncontrolled motion.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 9, 2021
Observations: Licensing observed an entanglement hazard at the top of the red slide using the entanglement device. This represents an immediate risk to the health and safety of children in care and must be corrected immediately. A plan for corrective action is to be submitted to Licensing by December 9, 2021. Full compliance will not be achieved until the plan has been implemented and completed.
3000 - SPS DOLSOP (Entanglement)
Description: Equipment is free of entanglement hazards in areas of uncontrolled motion. (Something around the child’s neck becomes caught on equipment)
Use Entanglement test device
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed through discussion with staff that the red slide is not in use by children in the facility as per the Health and Safety Plan submitted by Licensee.
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: Licensing observed two staff files with Criminal Record Check results. Two staff are no longer employed at the facility who had files missing Criminal Record Check results.
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: Ensure 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing reviewed 10 staff files. Six files were missing a Criminal Record Check.
3010 - CCLR 19(1)(c)
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 record of the person’s work history
Corrective Actions Required: Ensure 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 record of the person's work history.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing reviewed 10 staff files. Three files were missing a record of work history.
3010 - CCLR 19(1)(c)
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 record of the person’s work history
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed the staff with no record of work history on file, no longer works at the facility.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed one staff missing verification of ECE certificate is no longer employed at the facility. One file has an expired ECE certificate. Licensing discussed getting the verification of new ECE certificate when it arrives.
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: Ensure that each employee practices implementing the fire drill system at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing observed protable room had not practiced or recorded a fire drill in November. Room 9 had not practiced any fire drill since opening.
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 observed a record of fire drill being practiced each month.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3060 - CCALA 7(1)(b)(i)
Description: 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
Corrective Actions Required: Ensure they must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 10, 2021
Observations: Staff informed Licensing Officers that the red slide had been in use. There was an approved Health and Safety plan stating that the red slide would not be used by children in care.
3060 - CCALA 7(1)(b)(i)
Description: 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
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed through discussion with staff that the Health and Safety plan in place stating that the red slide would not be used is being followed. A baby gate is placed to create a visual reminder to not use the slide.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 immunization status is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing audited 11 children's files. One file was missing immunization status.
3070 - CCLR 57(2)(d)
Description: A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner (doctor's name and number does not apply to REC only) and emergency contact
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed two children's files with name and number of medical practitioner added. One child no longer attends.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 57(2)(d)
Description: A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner (doctor's name and number does not apply to REC only) and emergency contact
Corrective Actions Required: Licensee to ensure for each child, a record showing a name and telephone number of a medical practitioner is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing audited 11 children's files. Three files were missing the name and telephone number of a medical practitioner.
3070 - CCLR 57(2)(i)
Description: A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency
Corrective Actions Required: Ensure for each child, a photograph or digital image of the child is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing audited 11 children's files. Four files were missing photos.
3070 - CCLR 57(2)(i)
Description: A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed three children's files with photos added. One child with file missing a photo no longer attends the facility.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed daily outdoor checks logged for areas used by facility.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure licensee must keep a log of all inspections, maintenance & repairs for outdoor playspace.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 17, 2022
Observations: Licensing observed no evidence of outdoor checks being completed in portable or room 9.