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
November 3, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 17
Description: A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child
Corrective Actions Required: Ensure that the faclility is free from hazards.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 10, 2022
Observations: Licensing observed in Room 2 heavier items on a high shelf and in the Preschool room an electrical outlet accessible to children.
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 that all staff files contain a valid criminal record checks.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing audited seven staff files and three staff criminal record checks where from another organization.
3010 - CCLR 19(1)(c)
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 record of the person’s work history
Corrective Actions Required: Ensure that all staff files contain a record of work history.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing audited seven staff files and one staff file was missing a record of work history.
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required: Ensure that fire drills are practiced at least once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing observed that the last implemented fire drill for Room 2 Group Child Care (30 Months to School Age) and Room 3 (Preschool) was in September 2022.
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 that children have, at all 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: December 7, 2022
Observations: Licensing observed the staff schedule and in the first half an hour, every other week, the staff present did not hold a current valid first aid certificate.
3010 - CCLR 60(3)(a)
Description: A licensee must keep (a) in the case of employees, all records required under section 19 (1) [character and skill requirements] for the entire time that the subject of the records is an employee of the community care facility,
Corrective Actions Required: Ensure that a file is kept for the entire time an employee remains an employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing observed that one staff did not have a file.
3020 - CCLR 56(1)(c)
Description: A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment]
Corrective Actions Required: Ensure that the yearly emergency drill has been documented and recorded.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing observed that the yearly emergency drill had not been recorded.
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 that all children's files contain the name of a medical practitioner and the medical practitioner's telephone number.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing audited 14 children's files and two were missing the name of a medical practitioner's name and telephone number and one child's file was missing the telephone number of a medical practitioner.
3070 - CCLR 59(b)
Description: In respect of a record referred to in this Division, a licensee must (b) keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request,
Corrective Actions Required: Ensure that files are kept in a place that can be retrieved within a reasonable time on request.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing observed that one staff file was at another location and the historical fire drills and emergency drill were offsite.
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 that all staff documents are displayed in a prominent place in the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 7, 2022
Observations: Licensing observed three staff documents displayed in a non prominent place and two of the staff's documents were not displayed.