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
January 23, 2024
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 23, 2024
Observations: Licensing reviewed seven staff files and observed one file missing a criminal record check.
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 tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 23, 2024
Observations: Licensing reviewed seven staff files and observed one file missing record of immunizations and/or immunization status.
3040 - 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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 23, 2024
Observations: Licensing observed an epi pen required by one child had expired in November 2022 and an asthma inhaler, required by another child had expired May 6, 2023.
3070 - CCLR 56.1(2)(a)
Description: A licensee must keep a copy of the written statement, referred to in Section 19 of the Act, that the licensee delivers to persons who prepay part of the cost of services
Corrective Actions Required: Ensure to keep a copy of the written statement, referred to in Section 19 of the Act, that the licensee delivers to persons who prepay part of the cost of services.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 23, 2024
Observations: Licensing reviewed 12 children's files and observed one file missing record of repayment agreement.
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 to keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 23, 2024
Observations: Licensing reviewed 12 children's files and observed two files missing dates recorded of immunizations and one file missing record of Medical Services Plan Number.
3070 - CCLR 57(2)(b)
Description: A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
Corrective Actions Required: Ensure to keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 23, 2024
Observations: Licensing reviewed 12 children's files and observed one file missing date of enrollment.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 23, 2024
Observations: Licensing observed three of twelve children's files included medical care plans and of three medical care plans, Licensing observed two missing courses of action recommended and/or specific symptoms and instruction on when to administer medication.
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 to 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: February 23, 2024
Observations: Licensing observed three children's files of twelve included medication care plans and of the three care plans one had not been last reviewed with the parent within the past twelve months.