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
November 19, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 15(1)(b)
Description: A licensee must supply equipment, furniture and supplies that are located so as not to block or hamper an exit in the case of fire or other emergency (except SACSG only).
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed that the materials stored in the hallway to the rear entrance had been removed.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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: Ensure a criminal record check is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2024
Observations: Licensing reviewed six staff files. Two files did not contain a criminal record check. Staff stated that the Manager had applied for the CRCs.
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 character references in respect of the person are obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2024
Observations: Licensing reviewed six staff files. Five files did not contain references.
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:
Corrective Actions Taken By Licensee: Licensing observed evidence of training had been added to the staff file missing this information.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed immunization status had been added to the staff files missing this information.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 19(4)(a)
Description: A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry
Corrective Actions Required: Ensure all educator and assistant educators hold a vaild certificate under Division 2 and the Licensee had verified certification.
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 four educator certificates had not been verified.
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.
3060 - CCLR 14(4)(b)
Description: A licensee, other than a licensee who provides a care program described as either Preschool (30 Months to School Age) or Group Child Care (School Age), must have in a community care facility a sturdy surface for changing diapers, located outside the food preparation area, next to a wash basin
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed washbasins had been installed beside change tables in all three rooms.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3060 - CCLR 46(1)
Description: A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed staff wash hands after each diaper change.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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.
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:
Corrective Actions Taken By Licensee: Licensing observed medical insurance plan number, child's sex and immunization status had been added to the files missing this information.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed date of enrollment had been added to the files missing this information.
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 the certificate for all educators and assistants are posted in a prominent place.
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 certificates were not posted.