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
October 16, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 13(2)
Description: A licensee must ensure that the community care facility and the furniture, equipment and fixtures within it are clean and in good repair while children are in attendance.
Corrective Actions Required: Ensure the equipment for children in use are clean and in good repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed a diaper changing mat at the hallway bathroom on the first floor was not in good repair.
3000 - CCLR 16(4)(a)
Description: A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are suitable for the age and development of the children,
Corrective Actions Required: Ensure all indoor and outdoor play materials and equipment are suitable for the age and development of children.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing measured a climbing dome with 0.95m in height at the Infant toddler playground, and the composite slide was measured with 1.06m for Group Child Care (Under 36 months) which exceed the height requirement for this age of children.
3030 - CCLR 34(2)(b)
Description: Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Corrective Actions Required: Ensure the staff to children ratio is no less than permitted in Schedule E of CCLR.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed 6 children with one Infant and Toddler Educator and one Early Childhood Educator Assistance at the Fern Room, Group Child Care (Under 36 Months). The Licensee addressed the staff to children ratio during the Routine Inspection.
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 to operate the community care facility in manner that promote the health, safety & dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed no record of two-minute flush at the beginning of the day as stated in the corrective action plan from September 14 to 16, 2026.
3050 - CCLR 48(5)
Description: A licensee must ensure that safe drinking water is available to children.
Corrective Actions Required: Ensure safe drinking water is available to children.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed no record of two-minute flush at the beginning of the day as stated in the corrective action plan from September 14 to 16, 2026.
3070 - CCLR 55(1)(b)
Description: A licensee must immediately notify a parent or emergency contact if, while under the care or supervision of the licensee, the child is involved in, or may have been involved in, a reportable incident described in Schedule H.
Corrective Actions Required: Ensure parent notified immediately if the child is involved/ may have been involved in a reportable incident as describe in Schedule H.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed a staffing warning letter which stated an child was wandering at the facility on September 10, 2026, which the manager stated there had no incident records and the parents were not notified.
3070 - CCLR 55(2)(a)
Description: A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee,
Corrective Actions Required: Ensure to notified Licensing within 24 hours if child in care involved in/may have been involved in a reportable incident in Schedule H.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed a staffing warning letter which stated an child was wandering at the facility on September 10, 2026, which the manager stated there had no incident records and had not reported to Licensing.
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 record of the sex must be kept for each child's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing audited 24 children's files, one file did not contain the sex of the child.
3070 - CCLR 57(2)(b)
Description: A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
Corrective Actions Required: Ensure a date of enrollment must be kept for each child's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing audited 24 children's files, and one file did not obtained a date of enrollment.
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 record of medical practitioner must be kept for each child's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing audited 24 children's files, and one file did not obtained a record of medical practitioner.
3070 - CCLR 57(3)(a)
Description: A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached,
Corrective Actions Required: Ensure all children's files contained record of written consent to call an ambulance in case of accident/ illness if parent cannot immediately be reached.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing audited 24 children's files, and one file did not obtained a record of written consent from parent to call an ambulance in case of accident/ illness if parent cannot immediately be reached.
3070 - CCLR 57(3)(b)
Description: A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.
Corrective Actions Required: Ensure children's files contain a consent to release a child to someone other than parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing audited 24 children's files. One file was missing a consent to release a child to someone other than parent.
3070 - CCLR 58(2)(a)
Description: The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required: Ensure a care plan must be developed in consultation with parent and any person requested by a parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed a child who required extra support, specifically prescribed medication required on a as needed basis, indicated in the registration form has not developed a care plan.
3080 - CCLR 11(4)
Description: A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.
Corrective Actions Required: Ensure the certification or copy of the certification of any educator/assistant employed displayed in a prominent place.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 9, 2026
Observations: Licensing observed a certificate of Infant and Toddler Educator was not displayed in a prominent place.