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
May 11, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 15(1)(a)
Description: A licensee must supply equipment, furniture and supplies that are of sturdy and safe construction, easy to clean and free from hazards.
Corrective Actions Required: Ensure that equipment, furniture and supplies are sturdy, safe in construction, easy to clean and free of hazards.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing observed outdoor infant/toddler swing had protruding sharp metal edges that had cut through the protective plastic cover and climbing holes on a tall climbing wall that has cracked.
3000 - CCLR 16(3)(a)
Description: A licensee must ensure that the entire outdoor play area is enclosed in a manner that is suitable for the age and development of children, and will ensure that children are free of harm
Corrective Actions Required: Ensure that the entire outdoor play area is enclosed in a manner that is suitable for the age and development of children, and will ensure that children are free of harm.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing observed a gap measuring 4.5 inches on a outdoor gate in the play area of the kids cottage.
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: 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 12, 2022
Observations: Licensing observed cleaning solution, cleaning wipes and plastic bags accessible to children in care.
3000 - SPS DOLSOP (Depth)
Description: Depth guidelines for loose fill material (if protective surfacing used) :
minimum 15 cm (6”) for 1.5 metre (5’) equipment height
minimum 30 cm (12”) for 2.3 metre (7’) equipment height
(Consider surfacing table, Triax, etc.)
Corrective Actions Required: Ensure protective surfacing is adequate for the height of equipment.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 12, 2022
Observations: Licensing measured ground surfacing at 4 inches in depth for equipment 8.5 feet in height.
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 slides are free from entanglement hazards.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing used the entanglement device and detected a entanglement hazard off the right side of the yellow slide used by the School Age program. This represents an immediate risk to the health and safety of children in care and must be corrected immediately. A plan for corrective action is children in care would not use the slide until corrected. Full compliance will not be achieved until the plan has been completed and implemented.
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 a person employed a a community care facility has character references in respect to that person.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited nine staff files, one file was missing character references for a person employed at the community care facility.
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 a record showing a person's work history is kept for staff employed at the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited nine staff files, one file was missing a record of a staff's work history.
3010 - CCLR 19(1)(d)
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: copies of any diplomas, certificates or other evidence of the person’s training and skills
Corrective Actions Required: Ensure a record is kept showing evidence of training for persons employed at the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited nine staff files, two files were missing evidence of training.
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 a record of immunization status is kept for persons employed at the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited nine staff files, two files were missing immunization status for persons employed at the community care facility.
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 that a certificate for an educator or an assistant is verified.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited nine staff files, one file did not have a certificate validated with the ECE Registry.
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: May 25, 2022
Observations: Licensing observed that a fire drill was not recorded since September 29, 2021 in the Kids Cove room and since March 11, 2022 in the Langford room.
3040 - CCLR 53(2)(a)
Description: A licensee must ensure that a child’s medication is not accessible to any child, except that a child may have access to his or her own medication if
(a) the child’s parent has instructed the licensee to permit this,
Corrective Actions Required: Ensure that a child's medication is not accessible to any child, except that a child may have access to his or her own medication if the child's parent has instructed the licensee to permit this.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing observed one epi-pen accessible to children in care.
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 record of immunization status is kept for each child.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited 21 children files, one file for a child in care was missing records of immunization status.
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 record is kept for each child showing name and telephone number of medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited 21 children files, one file for a child in care was missing the name and telephone number of a medical practitioner.
3070 - CCLR 57(2)(i)
Description: A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency
Corrective Actions Required: Ensure a record is kept for each child showing a photo or digital image.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing audited 21 children files, one file was missing a photo or digital image of a child.
3070 - CCLR 57(3)(b)
Description: A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.
Corrective Actions Required: Ensure a written record is kept with permission to release a child to someone other than the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 12, 2022
Observations: Licensing audited 21 children files, one file was missing consent to release to someone other than a parent.
3080 - 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 that all corrective action plans are followed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing observed that a Corrective Action Plan included a documentation log to mitigate the risk of lead in water was not kept. Proposed Manager indicated the water was flushed and filters replaced, but they had forgotten to record it on the log.
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 that a certificate for an educator is posted in a prominent place at the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 25, 2022
Observations: Licensing observed that one certificate for an Early Childhood Educator Assistant had not been posted at the community care facility. Corrected at time of inspection.