Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)

North Douglas Preschool

Facility Type: Child Care - 300

Follow-Up

January 15, 2026
Score & Grade: 0 Grade:
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.
Code
Category/Description
3000 - CCLR 16(3)(a)
Description: A licensee must ensure that the entire outdoor play area is enclosed in a manner that is suitable for the age and development of children, and will ensure that children are free of harm
Corrective Actions Required: Ensure that the entire outdoor play area is enclosed in a manner that is suitable for the age and development of children, and will ensure that children are free of harm. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between December 2 and 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: A temporary secure fence would be used for the outdoor play area, and it would be monitored for gaps and weak points daily. Licensee Contact would complete additional monthly checks of the outdoor fenced area. Installation of a permanent fence would be reviewed with the North Douglas Child Care Society [Board of Directors]. The corrective action plan was reviewed and accepted by Licensing. On January 15, 2026, Licensing observed there was no change in the fence used for the outdoor play area. The facility had evidence that daily outdoor play inspections occurred. The Licensee Contact had not met with the North Douglas Child Care Society [Board of Directors] related to the installation of a permanent fence.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2026
Observations: Regarding intake September 4, 2025. Through the investigation process, Licensing determined that the parking lot was not suitable for the age and development of children as children were able to step on the top of the net in order in order to lower it and cross over it. On January 15, 2026, Licensing observed no changes made to the net.
3010 - 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 staff operate the community care facility in a manner that will promote the health, safety and dignity of persons in care and child(ren) are not subjected to physical restraint. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between December 2 and 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Staff would complete training in behaviour guidance, managing biting behaviours, emotion coaching, and supporting self-regulation for infants and toddlers, and complete ongoing professional development annually, and built into the annual professional development plan. Staff who demonstrated unsafe or inappropriate behaviour guidance would receive immediate coaching and may be removed from duty until retraining was completed. Licensee Contact would complete observations of each program weekly for three months and then monthly. The corrective action plan was reviewed and accepted by Licensing. On January 15, 2026, Licensing observed staff had not completed any training in behaviour guidance, and no annual professional development plan was completed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2026
Observations: Regarding intake September 4, 2025. Through the investigation process, Licensing determined that staff did not promote the health, safety and dignity of persons in care as a child in the Group Child Care (Under 36 Months) program was subjected to physical restraint as they were made to sit in a highchair after they had bit another child. Staff lacked the skills necessary to manage the child in an age appropriate manner.
3020 - CCLR 56(2)
Description: A licensee must ensure that the policies and procedures referred to in subsection (1) are implemented by employees.
Corrective Actions Required: Ensure that the policies and procedures referred to in subsection (1) are implemented by employees. Action/s Required by Licensee: Licensee to submit a correction action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between December 2 and 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The Behaviour Guidance policy would be updated to include highchairs, cribs or equipment may never be used for discipline and would be reviewed with staff signed off as read. Licensee Contact would complete biweekly observation rounds to confirm that staff were following the Behaviour Guidance policy. This would occur for three months and then monthly. The corrective action plan was reviewed and accepted by Licensing. On January 15, 2026, Licensing observed that the behaviour guidance policy was not updated and therefore staff did not sign off on the policy as read. The Licensee Contact did not have evidence of completion of rounds to confirm that staff was following the policy.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2026
Observations: Regarding intake September 4, 2025. Through the investigation process, Licensing determined that staff did not implement the behaviour guidance policy. The policy stated children were to be supported not punished. A child in the Group Child Care (Under 36 Months) program was punished when made to sit in a highchair after they had bit another child.
3030 - CCLR 52(1)(b)
Description: A licensee must ensure that a child, while under the care or supervision of the licensee, is not subjected to confinement or physical restraint by an employee, except as authorized in a child care plan if the plan includes instructions respecting behavioural guidance.
Corrective Actions Required: Ensure that a child, while under the care and supervision of the licensee, is not subjected to confinement or physical restraint by an employee, except as authorized in a child care plan if the plan includes instructions respecting behaviour guidance. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between December 2 and 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Staff would complete training in behaviour guidance, managing biting behaviours, emotion coaching, and supporting self-regulation for infants and toddlers, and complete ongoing professional development annually, and built into the annual professional development plan. Staff who demonstrated unsafe or inappropriate behaviour guidance would receive immediate coaching and may be removed from duty until retraining was completed. The corrective action plan was reviewed and accepted by Licensing. On January 15, 2026, Licensing observed staff had not completed any training in behaviour guidance, and no annual professional development plan was completed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2026
Observations: Licensing observed that the facility policy related to physical restraint was not updated, therefore staff did not review an updated policy.
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: On January 15, 2026, Licensing observed the Licensee Contact was reviewing incident reports to ensure submission as applicable and Licensing observed a checklist was created by the Licensee Contact for reportable incidents.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake September 4, 2025. Through the investigation process, Licensing determined that a child was involved in a reportable incident and the Medical Health Officer was not notified within 24 hours. Corrective Action: Ensure that the Medical Health Officer is notified 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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between December 2 and 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Licensee Contact would review incident reports to ensure submission to Licensing when applicable. The corrective action plan was reviewed and accepted by Licensing.