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
March 6, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - CCLR 19(1)(a)
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 criminal record check for the person
Corrective Actions Required: Ensure a valid Criminal Record Check is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2026
Observations: Licensing audited four staff files. One file did not contain a Criminal Record Check.
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 reference checks are obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2026
Observations: Licensing audited four staff files. One file did not contain a record of character references.
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 of the monthly fire drill is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2026
Observations: Licensing audited the monthly fire drill record, and observed the March, April and June 2025 fire drill were not kept. Staff stated they implemented the fire drills, but forgot to record them.
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 children's files contain a consent to release a child to someone other than parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2026
Observations: Licensing audited five children's files. One file did not contain a consent to release a child to someone other than the parent.
3070 - CCLR 59(b)
Description: In respect of a record referred to in this Division, a licensee must (b) keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request,
Corrective Actions Required: Ensure all staff records are kept in a place from which it can be retrieved within a reasonable time.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 20, 2026
Observations: Licensing observed the manager was not at the facility on this date. Staff stated that the character references had been completed electronically and that only the manager had access to the documentation.