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
July 15, 2022
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: Ensure a person is not employed in a community care facility unless a criminal record check for the person has been obtained.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited two staff and one volunteer file of which one staff was missing 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 a person is not employed in a community care facility unless character references in respect of the person have been obtained.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited two staff and one volunteer file of which one staff and one volunteer were missing character 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: Ensure a person is not employed in a community care facility unless the following have been obtained: copies of any diplomas, certificates or other evidence of the person’s training and skills.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited two staff and one volunteer file of which one staff was missing copies of any diplomas, certificates or other evidence of the person’s training and skills.
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 a person is not employed in a community care facility unless the following has been obtained: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited two staff and one volunteer file of which one staff was missing evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
3010 - CCLR 19(5)(b)
Description: Despite this section, a licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following: character references in respect of the person
Corrective Actions Required: Ensure character references are obtained in respect of the person.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited one volunteer file of which was missing character references in respect of the person.
3010 - CCLR 19(5)(c)
Description: Despite this section, a licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or 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 evidence is obtained that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited one volunteer file of which evidence that the person has complied with the Province’s immunization and tuberculosis control programs was missing.
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 each employee practices implementing the fire drill system at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Staff stated monthly fire drill and yearly emergency plan had not been implemented since May 2022.
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 current records are kept of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing observed no records respecting compliance with section 22(2)(b) and (c) [emergency training and equipment].
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 the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing observed one ECE and one RA working with 14 children in the Preschool Program.
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 community care facility must have in writing from a parent, and maintain at the community care facility, consent to call a medical practitioner or ambulance in case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing audited three children's files of which all were missing written consent to call a medical practitioner or ambulance.
3070 - CCLR 59(a)
Description: In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58,
Corrective Actions Required: Ensure in respect of a record referred to in this Division, the records referred to in sections 56 to 58 are kept in a single place at the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Staff stated the minor incident log book was off site and unable for Licensing to review.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure 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: September 15, 2022
Observations: Staff stated there was no regular log kept of inspections maintenance and repairs.