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)
Non-Visit Follow-up
December 20, 2022
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 licensee must not employ a person in a community care facility unless they have first met with the person and obtained 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: December 22, 2022
Observations: Licensing reviewed five staff files. One file was missing one character reference.
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:
Corrective Actions Taken By Licensee: Licensing received two letters of reference by email for a staff member.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received photo evidence by email of an emergency drill practiced and logged on December 1, 2022.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required: Ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 1, 2022
Observations: Licensing observed that an emergency drill had not been practiced since the facility opened.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received photo evidence by email of daily outdoor checks completed in both classrooms.
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 a log is kept of all inspections, maintenance and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 22, 2022
Observations: Licensing observed the outdoor checks had not been recorded November 21-24, 2022.
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:
Corrective Actions Taken By Licensee: Licensing received photo evidence by email of educator's certificates displayed on bulletin board in the classroom.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 1, 2022
Observations: Licensing observed two educators did not have certificates displayed at the facility.