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
3000 - SPS DOLSOP (Inspected)
Description: Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded
Corrective Actions Required: Ensure daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing observed there was not a daily record kept for all inspections, maintenance and repairs. Staff stated they inspected the playground daily and recorded in the attendance list. Licensing observed it was not recorded daily.
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 a criminal record check is obtained for employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing audited six staff files and one file did not contain a criminal record check. Staff stated they had applied for it on September, 2023 and were waiting for the results.
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 evidence of compliance with Province's immunization and TB control programs is obtained for employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing audited six staff files and one file did not contain immunization status.
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 educator or assistant holds valid certificate, Licensee has verified certification.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing audited six staff files and observed four certificates had not been verified through the ECE Registry. Staff stated the certificates were validated but not recorded.
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 a record is kept regarding the implementation of monthly fire drill system and yearly emergency plan practices.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing observed a current record was not kept for the fire dill system and yearly emergency plan practices. Staff stated they had implemented the fire drills and emergency drill but did not recorded.
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 a current record of medical insurance plan number is kept for each child.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing audited three children files and one file did not contain medical insurance plan number. Staff stated the child recently moved to the province and did not have medical insurance plan number.
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 a current record of a medical practitioner is kept for each child in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing audited three children's files and one file did not contain doctor's name. Staff stated the child recently moved to the province and did not have a medical practitioner.
3070 - CCLR 58(2)(b)
Description: The licensee must review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required: Ensure a care plan is reviewed at least once a year with a parent and any person requested by parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing observed three care plans were not reviewed at least once a year with a parent and any person requested by parent.
3080 - CCLR 11(4)
Description: A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.
Corrective Actions Required: Ensure certificates or copy of the certificate of any educator / assistant employed displayed in a prominent place.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing observed one certificate of one employed staff was not displayed in a prominent place.