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
February 8, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - CCALA 7(1)(d)
Description: A licensee must appoint a manager for the community care facility.
Corrective Actions Required: Ensure a manager is appointed to the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: February 10, 2023
Observations: Licensing observed that the previous manager left employment in May 2022 and no replacement manager had been appointed.
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 character references are obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 10, 2023
Observations: Licensing reviewed three staff files. One file did not contain character references.
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 evidence of training and skills is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 10, 2023
Observations: Licensing reviewed three staff files. One file did not have 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 immunization status is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 10, 2023
Observations: Licensing reviewed three staff files. One file did not contain 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:
Corrective Actions Taken By Licensee: Licensing observed that a fire drill had been practiced and recorded for January 2023. Staff stated that the facility was now completing monthly fire drills.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required: Ensure employees practice implementing the emergency plan at least once a year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 10, 2023
Observations: Staff stated that emergency drills had not been practiced.
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:
Corrective Actions Taken By Licensee: Licensing observed hooks had been installed for children to use for storage of belongings. Staff stated that children were handwashing before and after snack and that they had a designated snack table. Licensing observed the snack table was disinfected prior to use.
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: Ensure records are kept for each child showing immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 10, 2023
Observations: Licensing reviewed five children's files. One file did not contain immunization status.
3070 - CCLR 59(a)
Description: In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed that staff records were on site.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 59(a)
Description: In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58,
Corrective Actions Required: Ensure records referred to in Sections 56-58 are kept in a single 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: February 10, 2023
Observations: Licensing observed that one staff did not have a file on site.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed that a log was being kept of playground inspections.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: