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
November 4, 2025
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 a healthy and safe environment is provided at all times.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 21, 2025
Observations: Licensing observed the fire extinguisher was due for servicing on or before September 30, 2025.
3000 - CCLR 17
Description: A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed exposed electrical outlets covered this date.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 all staff have a valid criminal record check on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 21, 2025
Observations: Licensing audited three staff files, of which one did not have a criminal record check.
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 all staff have character references on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 21, 2025
Observations: Licensing audited three staff files, of which two were missing 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:
Corrective Actions Taken By Licensee: Licensing observed immunization status for staff files.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed validations for certificates on file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed a fire drill was completed for October 2025.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations:
3030 - CCLR 34(2)(b)
Description: Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Corrective Actions Required: Ensure the ratio of employees to children atttending a community care facility is no less 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: October 22, 2025
Observations: Licensing observed 10 children in care with one Early Childhood Educator (ECE). Additionally, during the inspection an additional child arrived and a Responsible Adult (RA). One Educator and one Assistant is required to be in ratio with 11 children, as permitted in Schedule E of the Child Care Licensing Regulation.
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 a program is established to instruct children in, and to practice the rules of health and hygiene.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 21, 2025
Observations: Licensing observed all children using the same towel to dry their hands in the washroom.
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:
Corrective Actions Taken By Licensee: Licensing observed a log of inspections, maintenance and repairs of the outdoor area.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed medical plan insurance number on file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed name and telephone number of a medical practitioner on file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: