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 13, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 children do not have access to any objects or substance that may be hazardous.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing observed there was construction materials, plywood with nail, and fence railing were placed at the outdoor area which children have access to it. The fence railing had been removed, and the plywood was being carried to a different location at the Routine inspection.
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 is kept for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing audited five staff files. Two files did not obtained a record of immunization status. The non-compliance items had been corrected during the Routine Inspection.
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 for the monthly fire drill and the yearly emergency drill.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing observed there was no record of the monthly fire drill in April 2026, and the yearly emergency plan practices. Manager stated they did the fire drill practice, but did not recorded, and could not find the record of the emergency drill.
3050 - 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 to operate the community care facility in a manner that will promote the health, safety & dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing observed no record of two-minute flush at the beginning of the day as stated in the corrective action plan. Manager stated they were not aware they had lead in water in the bathroom and snack room.
3050 - CCLR 48(5)
Description: A licensee must ensure that safe drinking water is available to children.
Corrective Actions Required: Ensure safe drinking water is available to children.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing observed no record of two-minute flush at the beginning of the day as stated in the corrective action plan. Manager stated they were not aware they had lead in water at the bathroom and snack room.
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 sex of the children must be kept for each child's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing audited six children's files. One file did not contain a record of sex of the child.
3070 - CCLR 57(2)(b)
Description: A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
Corrective Actions Required: Ensure a record of date of enrollment is kept in all children's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing audited six children files. One file did not obtain a record of date of enrollment.
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 of a medical practitioner is kept in the children's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 19, 2026
Observations: Licensing audited six children files. One file did not obtain a record of medical practitioner.