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)
Non-Visit Follow-up
December 21, 2021
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 that all children do not have access to any object or substance that may be hazardous to the health or safety of a child.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Licensing observed an unhinged bathroom stall door, leaning against the wall on the upper level of the facility.
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:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, photo evidence of the bathroom door being repaired and back up on the hinges.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 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 TB control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Licensing audited three staff files of which one was missing evidence that the person has complied with the Province's immunization and tuberculosis control programs.
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:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, photo evidence which showed a termination date for the employee who's file was missing record of immunization.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 29(c)
Description: To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, photo evidence which provided confirmation of termination date for the employee who's file was missing record of 20 hours training qualification.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 29(c)
Description: To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,
Corrective Actions Required: Ensure for employment in a community care facility as a responsible adult, a person must complete a course, or a combination of courses, of at least 20 hours in child development, guidance, health and safety, or nutrition.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Licensing audited three staff files of which one was missing evidence of a person having completed a course, or a combination of courses, of at least 20 hours in child development, guidance, health and safety, or nutrition.
3040 - CCLR 53(4)
Description: A licensee must ensure that an employee who supervises a child who self-administers medication documents the administration of the medication in the child’s care plan.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, photo evidence of a care plan for a child who self administers medication.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3040 - CCLR 53(4)
Description: A licensee must ensure that an employee who supervises a child who self-administers medication documents the administration of the medication in the child’s care plan.
Corrective Actions Required: Ensure that an employee who supervises a child who self-administers medication documents the administration of the medication in the child's care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Staff stated child who self-administers medication does not have a care plan.
3050 - CCLR 48(5)
Description: A licensee must ensure that safe drinking water is available to children.
Corrective Actions Required: Ensure that safe drinking water is available to children.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 1, 2021
Observations: On March 10, 2020, lab results dated March 4, 2020 for this facility were received by email. The results show that SAMPLES A and B are in excess of the Maximum Allowable Concentration (MAC) for the stagnant water and below the MAC for the 2 minute flush. Corrective action plan was requested from Licensee. A plan for corrective action is to be submitted to Licensing by September 1, 2021. Full compliance will not be achieved until the plan has been implemented and completed.
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:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, a picture of a child's file to include the name and telephone number of a medical practitioner.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 Licensee must keep, for each child, a record showing the following information: (d) the name and telephone number of a parent, medical practitioner and emergency contact.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Licensing audited 10 of 84 children's files of which one was missing the name and telephone number of a medical practitioner.
3070 - CCLR 58(1)(a)
Description: A licensee must keep, for each child requiring extra support, a current care plan showing the following information: the diagnoses relevant to the child’s requirement for extra support, as made by health care professionals
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, a picture of a child's care plan which showed a diagnosis relevant to the child's requirement of extra support required.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 58(1)(a)
Description: A licensee must keep, for each child requiring extra support, a current care plan showing the following information: the diagnoses relevant to the child’s requirement for extra support, as made by health care professionals
Corrective Actions Required: Ensure Licensee must keep, for each child requiring extra support, a current care plan showing the following information: diagnosis relevant to the child's requirement for extra support, as made by health care professionals.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2022
Observations: Licensing audited 10 of 84 children's files of which one was missing a current care plan showing a diagnosis relevant to the child's requirement for extra support, as made by health care professionals.
3070 - CCLR 58(1)(b)
Description: A licensee must keep, for each child requiring extra support, a current care plan showing the following information: the courses of action recommended by health care professionals to address the needs of the child requiring extra support
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, a picture of a child's care plan which showed the course of action recommended by health care professionals to address the needs of the 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(1)(b)
Description: A licensee must keep, for each child requiring extra support, a current care plan showing the following information: the courses of action recommended by health care professionals to address the needs of the child requiring extra support
Corrective Actions Required: Ensure Licensee must keep, for each child requiring extra support, a current care plan showing the courses of action recommended by health care professionals to address the needs of the child requiring extra support.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2022
Observations: Licensing audited ten of 84 children's files of which one was missing a current care plan showing the courses of action recommended by health care professionals to address the needs of the child requiring extra support.
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 received by email, dated August 30, 2021, a picture of a child's care plan which included a date recorded, providing evidence of when the care plan was last reviewed (July 3, 2021).
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: Ensure Licensee must review the care plan at least once each year with a parent if the child requiring extra support and any person requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Licensing audited ten of 84 children's files of which one was missing the date the care plan was last reviewed and/or created.
3070 - CCLR 58(3)(e)
Description: The licensee must record compliance with the care plan of a child requiring extra support in respect of each of the following that are applicable to the child:any other matter for which the licensee has agreed with the parent of the child to record compliance.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 31, 2021, a picture of a medication administration documentation record which provided evidence that this document is being maintained and that a child's care plan is compliant in recording any medication that is administered.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 58(3)(e)
Description: The licensee must record compliance with the care plan of a child requiring extra support in respect of each of the following that are applicable to the child:any other matter for which the licensee has agreed with the parent of the child to record compliance.
Corrective Actions Required: Ensure Licensee must record compliance with the care pan of a child requiring extra support in respect of each of the following that are applicable to the child: any other matter for which the Licensee has agreed with the parent of the child to record compliance.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Licensing audited 10 of 84 children's files of which one care plan of a child requiring extra support did not have record of compliance.
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:
Corrective Actions Taken By Licensee: Licensing received by email, dated August 30, 2021, three pictures of the facility's communication record/book which were: one picture of the book/log and two pages showing entries being made into the communication book as evidence that the facility is utilizing the book as a way of documenting daily activity, care plan administration and minor incidents.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 Licensee must of 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2021
Observations: Licensing observed communication book not being implemented as stated in approved health and safety plan dated July 6, 2021.