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 23, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 16(4)(a)
Description: A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are suitable for the age and development of the children,
Corrective Actions Required: Ensure that all indoor and outdoor play materials and equipment accessible to children are suitable for the age and development of the children.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 24, 2022
Observations: Licensing observed three playpens that each had an extra mattress placed in them. Manufacturer label stated to not add additional mattress.
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 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 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 26, 2022
Observations: Licensing reviewed eight staff files. Two files were missing CRC results.
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 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 character references in respect of the person.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 26, 2022
Observations: Licensing reviewed eight staff files. Two files were missing one character reference and one file was missing two character references.
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 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 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 26, 2022
Observations: Licensing reviewed eight staff files. Two files were missing 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 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 and the licensee has verified certification.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 26, 2022
Observations: Licensing reviewed eight staff files. Five files were missing verification of ECE or ECEA certificates.
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 system at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 26, 2022
Observations: Licensing observed fire drills had not been practiced from January to April.
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 licensee must keep current records respecting compliance with section 22(2)(b) and (c) [emergency training and equipment].
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 26, 2022
Observations: Licensing observed that there was no record of an emergency drill being practiced in the previous 12 months. Staff stated it was completed in December 2021 but not recorded.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 26, 2022
Observations: Licensing reviewed two care plans. One care plan had not been reviewed since March 2020.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure a log is kept of all inspection, maintenance and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 26, 2022
Observations: Licensing observed that daily outdoor checks had not been recorded consistently in any classroom.