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
April 28, 2026
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 that a healthy and safe environment is provided at al times while children are under supervision of employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed a cloth cover on diapering changing mat that licensee stated she changed at the end of the day, no sanitization was done between diaper changes.
3000 - CCLR 16(4)(b)
Description: A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are safely constructed, free from hazards and in good repair.
Corrective Actions Required: Ensure outdoor play equipment accessible to children are safely constructed and free from hazards.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed a Little Tikes slide placed over a concrete surface during children's outdoor free play. Licensing observed this corrected during inspection.
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 staff files obtain two character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed staff file for regular sub, that licensee stated worked on Fridays. File was missing two reference checks.
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 obtain a record of person's work history.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed staff file, that licensee indicated worked every friday missing record of work history.
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 staff files obtain immunization record status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed staff file, licensee indicated worked every Friday missing documentation of immunization status.
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 of emergency drills and fire drills are documented.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed no record of monthly fire drills or emergency drills were preformed or documented.
3030 - CCLR 34(2)(a)
Description: Without limiting subsection (1) a licensee must ensure that children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E, (except FCC/IHMACC/REC; child qualified if in age range or within one month (except GCC School Age)).
Corrective Actions Required: Ensure that children attending a community care facility are divided into groups, with each group having no more children 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: May 5, 2026
Observations: Licensing observed five children, ages: 3,3,2,2,1 in care. Family Child Care can have no more than four under four as per Schedule E.
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 the community care facility is operating in a manner that will promote the health and safety of children in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed no record of daily outdoor log inspection being maintained at the facility.
3060 - CCLR 14(4)(b)
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 wash basin
Corrective Actions Required: Ensure surface for changing is next to wash basin.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed diaper change area that was not located next to a wash basin. The change table was located in the nap room with a room separating the nap room and bathroom. Licensee stated that she used a change pad on the floor in the bathroom when she was first licensed.
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 children 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: May 15, 2026
Observations: Licensing observed that children did not wash hands prior to snack time.
3070 - CCLR 56(1)(f)
Description: A licensee must keep current records of each of the following: (f) a log of minor accidents, illnesses and unexpected events involving children, that did not require medical attention and were not reportable incidents described in Schedule H.
Corrective Actions Required: Ensure current records of each of the following are kept: a log of minor incidents, illness and unexpected events involving children, that did not require medical attention described in Schedule H.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed no current records of minor incidents, illnesses and unexpected events involving children, that did not require medical attention and were not reportable incidents described in Schedule H.
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 each children's file has a record showing immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing audited seven children's files, three were missing immunization status.
3070 - CCLR 57(2)(c)
Description: A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure
Corrective Actions Required: Ensure a record showing daily attendance of each child signed in and signed out times.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed no attendance record showing daily attendance for children with sign in and sign out times.
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 children's files contain name and number of medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed seven children's files, two files did not have medical practitioner name or number.
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: Ensure a record all children's files have record of persons not permitted access to child.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2026
Observations: Licensing observed seven children's files, seven had no record showing person not permitted to access child.