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)
Follow-Up
November 10, 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:
Corrective Actions Taken By Licensee: Licensing observed CRC results for one staff added to the file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 licensee must not employ a person in a community care facility the licensee or in the case of a person who is not the manager, a manager has first met with the person and obtained a criminal record check for the person.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing reviewed five employee files. One file 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:
Corrective Actions Taken By Licensee: Licensing observed two character references added to a staff file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 licensee must not employ a person in a community care facility the licensee or in the case of a person who is not the manager, a manager has first met with the person and 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 6, 2022
Observations: Licensing reviewed five employee files. Three files were missing immunization status.
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:
Corrective Actions Taken By Licensee: Licensing observed immunization status was obtained for three staff.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 19(4)(a)
Description: A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry
Corrective Actions Required: Ensure licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid certificate, which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing reviewed five employee files. One file was missing verification of ECE certificate.
3010 - CCLR 19(4)(a)
Description: A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed ECE certificate had been verified for one staff.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed two character references added to a volunteer file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed immunization status added to volunteer file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 at least once per month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing observed in room 243 a Fire Drill had not been practiced and/or recorded in July 2022.
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:
Corrective Actions Taken By Licensee: Licensing observed a fire drill was practiced and recorded monthly.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3050 - 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:
Corrective Actions Taken By Licensee: Licensing observed the daily flush recorded each day.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3050 - 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 licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing observed there is no evidence of a daily flush being completed in room 243 as stated in the approved Corrective Action Plan to mitigate the risk of positive lead in water results.
3060 - CCLR 14(4)(a)
Description: A licensee, other than a licensee who provides a care program described as either Preschool (30 months to School Age) or Group Child Care (School Age), must have in a community care facility a sturdy surface for changing diapers, located outside the food preparation area, next to a covered container for soiled clothing
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed a covered container next to the diaper change area in room 259.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3060 - CCLR 14(4)(a)
Description: A licensee, other than a licensee who provides a care program described as either Preschool (30 months to School Age) or Group Child Care (School Age), must have in a community care facility a sturdy surface for changing diapers, located outside the food preparation area, next to a covered container for soiled clothing
Corrective Actions Required: Ensure licensee must have a sturdy surface for changing diapers next to a covered container for soiled clothing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing observed there was no covered container for soiled clothing in room 259.
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:
Corrective Actions Taken By Licensee: Licensing observed immunization records obtained for four children's files. Two children no longer attend.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 licensee must keep for each child a record showing immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing audited seven children's files. Six files were missing immunization records.
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:
Corrective Actions Taken By Licensee: Licensing observed a child's file with the name and number of a medical practitioner added.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 licensee must keep for each child a record showing the name and number of a medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing audited seven children's files. One file was missing the name and number of a medical practitioner.
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:
Corrective Actions Taken By Licensee: Ensure licensee must keep, for each child a record of any person not permitted access to child.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing audited seven children's files. One file was missing record of persons not permitted access to child.
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:
Corrective Actions Taken By Licensee: Licensing observed a child file with a space for persons not permitted.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 58(2)(a)
Description: The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required: Ensure licensee must develop the care plan in consultation with the parent of a child requiring any extra support and any person requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing audited seven children's files. Three files stated the child had an inhaler for use. Licensing did not observe a medical care plan on file.
3070 - CCLR 58(2)(a)
Description: The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed a care plan developed for a child with an inhaler. Two children no longer attend.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed the outdoor playspace check documented daily in room 259.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure log is kept of all inspections, maintenance and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing observed in room 259 log had not been kept of outdoor checks.