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 21, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 all staff files have character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 10, 2023
Observations: Licensing audited two staff files and observed one staff file did not have character references.
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 all staff files have record of work history.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 10, 2023
Observations: Licensing audited two staff files and observed one missing work history. Licensing observed this corrected at the time of inspection.
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 all staff files have evidence of immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 10, 2023
Observations: Licensing audited two staff files and observed one missing evidence of immunization status.
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 ratio of employees to children is no less that permitted in Schedule E.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 21, 2023
Observations: Licensing observed a Responsible Adult working alone with six children at the time of arrival in a Multi Age Program. Approximately, four minutes later the Licensee entered through the facility door.
3040 - CCLR 53(1)(a)
Description: If a licensee has agreed with a parent to give a child any medication prescribed by a medical practitioner or provided by the parent, the licensee and his or her employees must ensure that the medication is (a) administered to the child in the amount and at the times specified by the child’s parent or in the child’s record or care plan
Corrective Actions Required: Ensure medication is administered in amount and at times specified by parent or in child's record.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 10, 2023
Observations: Licensing observed two medication forms in two children's files had medicine instructions to administer medicine without the time the medication had been administered and in what amount by staff.
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: Ensure the program practice rules of health and hygiene.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 21, 2023
Observations: Licensing observed a staff change a child on a diaper mat on the floor. The dipaer mat was put back on the change table and not disinfected after diaper change. The spray bottle for disinfecting the diaper change table was in the kitchen area of the facility.
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 current records are kept for each child's file showing medical insurance number.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 10, 2023
Observations: Licensing audited seven children's files and observed one missing medical insurance number. Licensing observed the medical insurance number obtained during the time of inspection.
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 current records are kept for each child showing name and telephone number of the emergency contact.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 10, 2023
Observations: Licensing audited seven children's files and observed one missing emergency contact name and telephone number and one missing emergency telephone number.