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
September 7, 2022
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 object or substance that may be hazardous to the child's health and safety.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing observed toys up high on shelves in areas where children play and nap.
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 all Criminal Record Checks are specific for the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing audited six staff files and observed one staff file had a CRC from a different organization.
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 fire drills are performed and recorded monthly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing observed the fire drills had not been preformed or recorded in one of the multi age rooms since June 2022. Staff stated they do fire drills separately.
3030 - CCLR 34(2)(a)
Description: Without limiting subsection (1) a licensee must ensure that children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E, (except FCC/IHMACC/REC; child qualified if in age range or within one month (except GCC School Age)).
Corrective Actions Required: Ensure children to staff ratio's for multi age are no more than set out in Schedule E.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 7, 2022
Observations: Licensing observed four children under 36 months in one program and five under 36 months in the other multi age program which exceeds the maximum allowed under 36 months for Multi Age children care.
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 all children's files have status of immunization.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing audited children's files and observed three files missing immunization status.
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 all children's files have medical practitioner name and telephone number.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing audited seven children's files and observed one missing medical practitioner name and telephone number.
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: Ensure all children's files have photographs or digital images of children.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing audited seven children's files and observed two files missing photo of child.
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: Ensure all care plans are reviewed once a year in consultation with parents.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing observed one care plan had not been updated in consultation with parents since July 2021.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure outdoor log is recorded daily of outdoor inspections.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing observed outdoor log had not been kept since August 25, 2022.
3080 - CCLR 11(4)
Description: A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.
Corrective Actions Required: Ensure all staff have certificates are displayed in a prominent place in the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 7, 2022
Observations: Licensing observed two staff working in one of the Multi Age rooms did not have certificates posted.