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
February 25, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 being implemented and documented once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 25, 2026
Observations: Licensing observed that fire drills in both programs were not being implemented and documented once a month.
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required: Ensure that emergency drills are being implemented and documented at least once a year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 25, 2026
Observations: Licensing observed that there was no documentation of an emergency drill be completed in 2025.
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 fire and emergency drills are being documented.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 25, 2026
Observations: Licensing observed that fire and emergency drills were not being documented.
3040 - CCLR 53(1)(b)
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 (b) readily accessible to employees.
Corrective Actions Required: Ensure that allergy-related medications (e.g., Epi-Pen) have a care plans associated with them.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 25, 2026
Observations: Licensing observed that an Epi-Pen was in one of the emergency backpacks, but no care plan or medical sign off was completed.
3070 - 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 that play space checks are being completed and documented.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 25, 2026
Observations: Licensing observed that play space checks were not being documented.