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
January 19, 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 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: February 16, 2022
Observations: Licensing audited 8 staff files and observed by admission from the Manager that two staff members did not yet have completed criminal record checks.
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 all of the following: (b) 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: February 16, 2022
Observations: Licensing audited 8 staff files and observed three staff files missing two written character references and one staff file containing only one written character reference.
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: 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 all of the following: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 16, 2022
Observations: Licensing audited 8 staff files and observed: Two staff files did not contain evidence of the staff immunization status. During the time of inspection one staff corrected this by submitting a record of immunization status.
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: February 16, 2022
Observations: Licensing observed by admission from the Manager that the school age care on school grounds program has not practiced monthly fire drills for Sept, Oct, Nov, Dec 2021; Manager stated that students participate in school fire drills which are outside of the school age after school care program.
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: Ensure 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 16, 2022
Observations: Licensing audited 8 staff files and observed: One staff file did not contain evidence that the staff member has completed at least 20 hours of education related to child development, guidance, health and safety or nutrition.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations: Licensing observed no evidence of a record that records monthly and yearly emergency drills in the school age care on school grounds program.
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: Ensure, 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 16, 2022
Observations: Licensing observed the following:
(1). Licensing audited 14 children's files and observed: 4 Children's Immunization records were not able to be produced. Manager stated that the immunization records are stored in the children's school files or at the nurse's office. During the time of inspection the records could not be produced for Licensing to review.
(2). Licensing observed by admission from the Manager that two children's care plans are kept in the child's school record file at the nurse's office and could not be produced at the time of inspection for Licensing to review.