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)
Follow-Up
January 28, 2025
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:
Corrective Actions Taken By Licensee: Licensing reviewed seven staff files. All files contained a valid criminal record check.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 reviewed seven staff files. All files contained references.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 that children attending the community care facility are divided into groups with each group having no more children than permitted in Schedule E.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 22, 2024
Observations: Licensing observed ten children with two educators in the Group Child Care (Under 36 Months) program. This service type requires one educator for every four children.
3070 - CCLR 10(2)(a)
Description: Licensees must not make any structural change to a community care facility unless the licensee first (a) submits plans for the change to a medical health officer, (except SACSG only)
Corrective Actions Required: Ensure plans are submitted to the MHO before any structural changes are made to the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2024
Observations: Licensing observed that plans had not been submitted to Licensing prior to moving walls to increase the size of room 3 and removing the approved diaper change area. On November 19, 2024, Licensing observed that additional structural change had occurred. Licensee removed a wall which increased the size of room 1 and eliminated the separate nap area assigned to room 3.
3070 - CCLR 10(2)(b)
Description: Licensees must not make any structural change to a community care facility unless the licensee first (b) receives written approval from the medical health officer. (except SACSG only)
Corrective Actions Required: Ensure written approval is obtained from the MHO before making structural changes to the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2024
Observations: Licensing observed structural changes to the facility had been completed without approval from Licensing. On November 19, 2024, Licensing observed that additional structural change had occurred without approval.