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
May 28, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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 a log of all inspections, maintenance and repairs is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing observed a log of all inspections, maintenance and repairs was not kept.
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 for all employees is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four staff files and one file did not contain a criminal record check.
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 are obtained for employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four staff files and two files did not contain character references.
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: Ensure an immunization status for employees is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four staff files and one staff file did not contain an immunization status.
3010 - CCLR 23(1)(a)
Description: A licensee must ensure that children have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,
Corrective Actions Required: Ensure children have at all the times, immediate access to an employee who holds a valid first aid and CPR certificate.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four staff files and observed two staff did not have a valid first aid and CPR certificate. Staff stated on May 27, 2025 all children were in care with a staff that did not have a first aid certificate.
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 showing an immunization status is kept for each child in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four children's files and observed all files did not contain an immunization status.
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 showing a medical practitioner name and phone number are kept for each child in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four children's files and two files did not contain medical practitioner name and phone number.
3070 - CCLR 57(2)(j)
Description: A licensee must keep, for each child, a record showing the following information: (j) a record of any person who is not permitted access to the child
Corrective Actions Required: Ensure a record of any person not permitted access to child is kept for each child in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four children's files and all files did not contain a record of any person not permitted access to child.
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 a written consent from parent to call a medical practitioner or ambulance in case of accident or illness and parent cannot immediately be reached is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2025
Observations: Licensing audited four children's files and all files did not contain a written consent from parent to call a medical practitioner or ambulance in case of accident or illness and parent cannot immediately be reached.