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
April 14, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: No further action required; this contravention has been addressed.
To Be Corrected By: May 26, 2023
Observations: On April 26, 2023 Licensing reviewed five staff files and observed three of five files missing two written character references.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 26, 2023
Observations: On April 26, 2023 Licensing reviewed five staff files and observed two of five files missing a record of the person's work history.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 26, 2023
Observations: On April 26, 2023 Licensing reviewed five staff files and observed two of five files missing copies of training certificates or evidence of training skills obtained for the employees.
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: May 26, 2023
Observations: On April 26, 2023 Licensing reviewed five staff files and observed five of five files missing evidence 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 a Licensee must 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: May 15, 2023
Observations: On April 14, 2023 Licensing observed no record or other evidence that staff had conducted monthly fire drills.
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, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2023
Observations: Licensing observed on April 14, 2023, no record related to documenting monthly fire or yearly emergency drills.
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 a Licensee must keep, 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: May 15, 2023
Observations: On April 14, 2023 Licensing reviewed eight child files and observed four of eight child files missing immunization records.
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: Ensure a Licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2023
Observations: On April 14, 2023 Licensing reviewed eight child files and observed three of eight child files 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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2023
Observations: On April 14, 2023 Licensing reviewed eight child files and observed one of eight child files missing a photograph or digital image.
3070 - CCLR 59(a)
Description: In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58,
Corrective Actions Required: Ensure, in respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2023
Observations: On April 14, 2023 Licensing observed no records available at the facility related to staff files; Manager stated that this information was located at the school district office and could not be obtained while Licensing was present at the facility on April 14, 2023.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure a log is kept of all inspections, maintenance & repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2023
Observations: On April 14, 2023 Licensing observed no record log of daily outdoor play space checks. Licensing observed the Manager state that daily outdoor play space checks are conducted by herself at the end of each school programming day, but that staff had not been recording the outdoor checks on the log.