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
September 18, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required: Ensure that each employee practices implementing the fire drill system at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 29, 2022
Observations: Licensing audited 2021 and 2022 fire and emergency drill logs and observed monthly fire drills for May, June and September 2021 and February 2022 were not conducted.
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed an email, dated June 29, 2022, which contained a photograph of a fire and emergency drill record; the record included two fire drills recorded and dated June 20, 2022 and June 24, 2022.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed an email dated June 29, 2022, which included a photograph of a fire and emergency drill record; the record included an entry of a once yearly emergency drill recorded and dated June 24, 2022.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations:
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required: Ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 29, 2022
Observations: Licensing observed from auditing the fire and emergency drill log that the last time a once yearly emergency drill was conducted was November 17, 2020.
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 an email, dated June 29, 2022, that contained two photograph's of a child's care plan; the photograph's included a parent signature on the care plan with a date of June 28, 2022 which indicated the care plan had been reviewed.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 29, 2022
Observations: Licensing audited 7 of 20 children's files and observed one medical care plan for a child was last reviewed in January 2021.