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
March 30, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing reviewed five staff files. All files contained a record of the person's work history.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing reviewed five staff files. All files contained evidence of training.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed a record was kept of fire drills.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3050 - CCLR 48(5)
Description: A licensee must ensure that safe drinking water is available to children.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - CCLR 57(2)(f)
Description: A licensee must keep, for each child, a record showing the following information:
(f) any medication administered to the child, including the amount and the time at which the medication was administered
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - CCLR 57(2)(f)
Description: A licensee must keep, for each child, a record showing the following information:
(f) any medication administered to the child, including the amount and the time at which the medication was administered
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed that medication permission forms were created for the children with epi-pens. Medication forms for medication no longer in use had been removed from children's records.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing reviewed ten children's files. All files contained a photograph of the child.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 58(2)(a)
Description: The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - CCLR 58(2)(a)
Description: The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed that a care plan had been developed for a child requiring extra support.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 58(2)(b)
Description: The licensee must review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed that care plans had been reviewed by the parents within one year.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 58(2)(b)
Description: The licensee must review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
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:
Corrective Actions Taken By Licensee: Licensing observed that all employees had employee files 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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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 of outdoor checks was being recorded.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - CCLR 11(1)
Description: A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - CCLR 11(1)
Description: A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Corrective Actions Required:
Corrective Actions Taken By Licensee: This was corrected at the time of the Routine Inspection.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: