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
October 5, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 16(4)(a)
Description: A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are suitable for the age and development of the children,
Corrective Actions Required: Ensure all indoor materials are suitable for the age and development of the children.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 12, 2022
Observations: Licensing observed there was one table and no chairs in the Group Child Care (30 Months to School Age) program. Staff stated the furniture was shipped and should arrive next week.
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 their health or safety.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 12, 2022
Observations: Licensing observed large, heavy boxes leaning against the wall in the Group Child Care (30 Months to School Age) program.
3000 - SPS DOLSOP (Inspected)
Description: Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded
Corrective Actions Required: Ensure thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2022
Observations: Manager stated the Group Child Care (30 Months to School Age) program did not perform or record daily inspections of the outdoor play area.
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 staff have valid criminal record checks on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 17, 2022
Observations: Licensing audited nine staff files; three had criminal record checks from a different organization and one did not have 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 all staff have character references on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2022
Observations: Licensing audited nine staff files and eight were missing character references.
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: Ensure all staff have a record of their work history on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2022
Observations: Licensing audited nine staff files and two were missing a record of the person's work history.
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 all staff have copies of any diplomas, certificates or other evidence of the person's training and skills on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2022
Observations: Licensing audited nine children's files and five were missing copies of any diplomas, certificates or other evidence of the person's training and skills.
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 all staff have immunization status on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 1, 2022
Observations: Licensing audited nine staff files and six were missing immunization status.
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 that permitted in schedule E.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 12, 2022
Observations: Licensing observed seven children in the Group Child Care (30 Months to School Age) program with a Responsible Adult (RA). An Early Childhood Educator (ECE) is required to be in ratio for this category of care.
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: Ensure a program is established to instruct children in, and to practice the rules of, health and hygiene.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 5, 2022
Observations: Licensing observed mats on the ground in the Group Child Care (30 Months to School Age) program which children sat on to eat.
3070 - CCLR 57(1)(a)
Description: A licensee must keep current records for each child showing (a) the information set out in subsection (2)
Corrective Actions Required: Ensure records are kept for all children in care showing the information set out in subsection (2).
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 12, 2022
Observations: Licensing observed one child in care who did not have a registration file.
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 have medical insurance plan numbers and immunization status on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 12, 2022
Observations: Licensing audited 10 children's files; two of which were missing medical insurance plan numbers and one was missing immunization status.
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 have a photo or digital image on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 12, 2022
Observations: Licensing audited 10 children's files; one of which was missing a photo or digital image.
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 facility records referred to in Sections 56-58 are kept in a single place at 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: Staff files were not on site for Licensing to review. Manager stated over the phone they were kept offsite. Additionally, Licensing could not find the fire drill log and the outdoor play space log to review. Staff stated they did not know where they were kept.
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 the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 12, 2022
Observations: Licensing observed four children in care in the Group Child Care (School Age) program upon arrival at 2:00 p.m. Staff stated the children had an early dismissal and were in care at 12:00 p.m. The hours of operation on the licence for Group Child Care (School Age) indicate the program starts at 2:37 p.m. Additionally, Licensing observed attendance records for the month of September which indicated the facility was operating the Group Child Care (30 Months to School Age) program prior to September 21, 2022 when the amended licence was effective.
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: Ensure the licence is displayed in a prominent 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: October 12, 2022
Observations: Licensing did not observe the licence displayed at the facility.