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
August 7, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 13(1)
Description: A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees
Corrective Actions Required: Ensure fire extinguishers are maintained at least once annually.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations: Licensing observed the fire extinguisher in the kitchen required annual maintenance before April 30, 2024. Licensee stated two additional fire extinguishers in the home also required annual maintenance before April 30, 2024.
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 criminal record checks are renewed prior to their expiry date.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 15, 2025
Observations: Licensee's criminal record check expired February 28, 2025.
3010 - CCLR 20(1)
Description: The licensee must not permit a person over the age of 12 to be ordinarily present on the premises of a community care facility while children are present, unless the person is of good character and the licensee has obtained a criminal record check for that person.
Corrective Actions Required: Ensure all persons over the age of 12 living in the home have a valid criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 15, 2025
Observations: Licensing observed two persons of the age of 12 living in the home had expired criminal record checks.
3020 - 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: The Licensee's Active Play Policy should reflect what the facility is actually doing. If the outdoor play area is not being used as the designated outdoor play area for Active Play, the Licensee is required to submit either an Off Site Outdoor Play Space Plan for review and approval, or information on how Active Play and a minimum of 60 minutes outdoor play per day is being met. Parents should receive a copy of the Active Play Policy.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 15, 2025
Observations: Licensing reviewed the In House Log Book and determined after discussion with the Licensee, that the designated outdoor play area had not been used between January - April 2025 due to weather conditions. The facility has an Active Play policy provided to parents that states at least 210 minutes of outdoor activities will be provided daily to children in care.
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 MSP numbers and immunizations records are obtained for all children enrolled in the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 15, 2025
Observations: Licensing reviewed six children files. Once child was missing MSP number and immunization status.
3070 - CCLR 57(2)(i)
Description: A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency
Corrective Actions Required: Ensure all children in care have a photo or digital image that could identify them in an emergency.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 15, 2025
Observations: Licensing reviewed six children's records. One child did not have a photo or digital image to identify them in an emergency. Three children had photos from when they were infants and needed updated photos that could identify them at their current age, should there be an emergency.