Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)

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Facility Type: Child Care - 300

Follow-Up

March 6, 2026
Score & Grade: 0 Grade:
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.
Code
Category/Description
3000 - CCLR 13(3)(a)
Description: A licensee must ensure that, on the premises of a community care facility or in a vehicle used by employees to transport children, no one engages in restricted consumption while children are under the supervision of employees.
Corrective Actions Required: Ensure no restricted consumption is used on the premise or in vehicles while children are under supervision. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Policies would be reviewed verbally with all staff members during a staff meeting in February 2026. Staff would acknowledge their understanding of the policies and sign the employee handbook acknowledgement. Documentation would be kept. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed staff had reviewed updated policies including the smoking policy, and all employees had signed off on the employee handbook. Policy acknowledgement forms were kept.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that staff were vaping on the premises, including parking lot, bathroom and office.
3010 - 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 and dignity of persons in care, specifically, suitability of the Manager. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: The Licensee Contact would complete learning sessions on tools to support strained relationships with families, increased behaviour complexities in group child care, and staffing stretches by January 14, 2026. The Licensee Contact would also continue taking courses delivered by the ECE Registry in order to complete their ECE certification. Certificates or proof of attendance would be retained. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, the Licensee Contact stated that they had attended two courses but had not yet obtained the certificates. They indicated that they would provide Licensing with an email or other evidence confirming their attendance. On March 6, 2026, after the inspection, Licensing received an email from the Licensee Contact confirming attendance at two professional development sessions: one held on January 14, 2026, and another on March 2, 2026.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that the Manager did not demonstrate the skills and abilities to carry out the duties as assigned.
3010 - 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 and dignitity of persons in care, specifically, staffing skills. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Staff would receive training on confidentiality, privacy, professional communication, behaviour guidance, and reporting procedures. Training was to be completed by February 20, 2026, and related documents would be kept. Staff members would take training webinars regarding positive behavioural guidance. The corrective action plan was reviewed and accepted by Licensing. On March 6, 2026, Licensing observed that staff members had not taken any training webinars. The Licensee Contact stated that staff members would complete the webinars between March 9 and 16, 2026. Documentation would be sent to Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 30, 2026
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that staff members did not demonstrate the skills and abilities to carry out the duties as assigned when they used a not an age appropriate behavioural guidance and did not implemented the policies.
3020 - CCLR 56(2)
Description: A licensee must ensure that the policies and procedures referred to in subsection (1) are implemented by employees.
Corrective Actions Required: Ensure that policies and procedures are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Policies would be reviewed verbally with all staff members during a staff meeting in February 2026. Staff would acknowledge their understanding of the policies and sign the employee handbook acknowledgement. Documentation would be kept. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed staff had reviewed updated policies, and all employees had signed off on the employee handbook. Policy acknowledgement forms were kept.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that policies were not implemented by staff members such as not smoking on the premises and behavioural guidance.
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 is no less than permitted in Schedule E. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Ratios would be monitored through attendance records and staffing schedules, and documentation would be kept. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed 14 children in care with three staff members (ECE, ECE, ECEA) in the Group Child Care (30 Months to School Age) program. Licensing also conducted an audit of staff attendance records and schedules for February and March 2026 which indicated compliance with the legislation.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that the ratio of employees to children was less than permitted in Schedule E when Early Childhood Educator Assistants opened and closed the program longer than 30 minutes when an Early Childhood Educator was required in ratio.
3030 - CCLR 39(1)
Description: A licensee must ensure that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.
Corrective Actions Required: Ensure children are supervised at all times by an Educator, Assistant or Responsible Adult. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Staff would receive training on supervision strategies and line-of-sight requirements. Training would be completed by February 20, 2026, and related documents would be kept. Licensee Contact would conduct and document monthly supervision observations. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed documentation confirming that a staff meeting was held on February 13, 2026. During this meeting, staff reviewed several key topics, including supervision expectations and strategies. Attendance records and meeting minutes for this meeting were kept.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that children were not supervised at all times when staff members were sleeping in the nap room on multiple occasions.
3030 - CCLR 51(1)(a)
Description: A licensee must ensure that behavioural guidance is appropriate to the age and development of the child who is receiving the guidance,
Corrective Actions Required: Ensure the behavioural guidance is appropriate to age and development of child receiving guidance. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Staff would receive training on professional communication and behavioural guidance. Training would be completed by February 20, 2026, and related documents would be kept. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed documentation confirming that a staff meeting was held on February 13, 2026. During this meeting, staff reviewed several key topics, including behavioural guidance and harmful actions not permitted. Attendance records and meeting minutes for this meeting were kept.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that the behavioural guidance used by staff was not age appropriate to age and development when staff used loud and firm voices and physically guide children by holding their arms or wrists. Staff used harmful comments toward children as behavioural guidance.
3030 - CCLR 52(1)(c)
Description: A licensee must ensure that a child, while under the care or supervision of the licensee, is not subjected to any of the following: (c) harsh, belittling or degrading treatment by an employee or another child, whether verbal, emotional or physical, that could humiliate the child or undermine the child’s self respect
Corrective Actions Required: Ensure children are not subjected to harsh/ belittling/ degrading treatment by an employee or another child that could humiliate the child or undermine their self-respect. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Staff would receive training on professional communication and behavioural guidance. Training would be completed by February 20, 2026, and related documents would be kept. Staff members would take training webinars regarding positive behavioural guidance. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed documentation confirming that a staff meeting was held on February 13, 2026. During this meeting, staff reviewed several key topics, including supervision expectations and strategies, behavioural guidance and respectful communication expectations. Attendance records and meeting minutes for this meeting were kept.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that children were subjected to belittling, harsh, degrading treatment by staff members when they restrained a child and verbally expressed harmful comments at the child.
3070 - CCLR 55(2)(a)
Description: A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee,
Corrective Actions Required: Ensure the Medical Health Officer is notified within 24 hours if children enrolled have been or may have been involved in a reportable incident described in Schedule H. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Staff would receive training on reporting procedures. Training would completed by February 20, 2026, and related documents would be kept. Schedule H would be posted in the classrooms to ensure 24 hours notification. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed documentation confirming that a staff meeting was held on February 13, 2026. During this meeting, staff reviewed several key topics, including reportable incidents under Schedule H. Attendance records and meeting minutes for this meeting were kept.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that multiple reportable incidents such as restraints and aggressive or unusual were not reported to the Medical Health Officer.
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 to operate the community care facility in a manner that will promote the health, safety and dignity of persons in care, specifically, confidentiality. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 26 and 27, 2026, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included: Staff would receive training on confidentiality. Training would be completed by February 20, 2026, and related documents would be kept. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee: On March 6, 2026, Licensing observed documentation confirming that a staff meeting was held on February 13, 2026. During this meeting, staff reviewed several key topics, including confidentiality and privacy. Attendance records and meeting minutes for this meeting were kept
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Regarding intake November 17, 2025. Through the investigation process, Licensing determined that photos and videos of children in care were posted on social media and confidentiality was breached.