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
June 13, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: September 26, 2024
Observations: Licensing observed that the fire drill had only been implemented four time since the last Routine Inspection. The dates were as follows: May 4, 2023, September 20, 2023, November 21, 2023 and February 27, 2024.
3050 - 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 the community care facility operates 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: June 27, 2024
Observations: Licensing reviewed corrective action plan dated May 16, 2024 which had not been followed. CAP indicated in part:
• All staff will receive additional training on reportable incidents, focusing on the timing of reporting, when to report them, how to report them, and who to report them to. All Staff will be required to sign off, noting that they have received this training.
• All staff will have received training and have reviewed the "child protection manual" by the end of the month (May 2024).
Licensing observed no documents signed by staff indicating this had been completed by the end of May. This was confirmed by the Manager.
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: Licenisng received an email and photo documentation indicating that the sex of the child had been updated on all children's files and future registration packages. This was confirmed at the Follow Up Inspection.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: