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
December 5, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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:
Corrective Actions Taken By Licensee: Licensing observed a climbing apparatus where the climbing materials were secured .
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - SPS DOLSOP (Entanglement)
Description: Equipment is free of entanglement hazards in areas of uncontrolled motion. (Something around the child’s neck becomes caught on equipment)
Use Entanglement test device
Corrective Actions Required: Ensure that play equipment is free from entanglements.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2024
Observations: Licensing detected an entanglement on the right side of a slide. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Licensee Contact stated that the children would not use that slide until it has been fixed. Full compliance will not be achieved until the plan has been implemented and completed.
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 that all staff files contain a record of a criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2024
Observations: Licensing audited four staff files and one file was missing a criminal record check. The staff file contained a criminal record check from another organization.
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 that all staff files contain character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2024
Observations: Licensing audited four staff files and two files were missing records of 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 that all staff files contain immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2024
Observations: Licensing audited four staff files and two files were missing records of immunization status.
3010 - CCLR 21(1)
Description: A licensee must not continue to employ a person in a community care facility unless the licensee has evidence that the person continues to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that all staff files contain a record of immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2024
Observations: Licensing audited four staff files and three files were missing a record of immunization status.
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 a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2024
Observations: Licensing observed that a fire drill was not practiced in the month of March 2024.