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
July 15, 2022
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 criminal record check is obtained for staff.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: Licensing audited eight staff files. One staff file did not have a CRC on file.
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 character reference checks are obtained for staff.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: Licensing audited eight staff files. One staff file was missing one character reference check.
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 copies of any diplomas, certificates or other evidence of the person's
training and skills is obtained for staff.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: Licensing audited eight staff files. One staff file was missing evidence of copies of any diplomas, certificates.
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 staff immunization status is obtained.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: Licensing audited eight staff files. One staff file was missing their immunization status.
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 a record of the monthly fire drill and emergency plan is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: Licensing did not observe a record of the monthly fire drill and the yearly emergency plan being implemented.
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 the name and number for a medical practitioner is obtained for children's files.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: Licensing audited 12 children's files. Three children's files did not have the name and telephone number of a medical practitioner.
3070 - CCLR 57(3)(b)
Description: A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.
Corrective Actions Required: Ensure a record to release a child to someone other than the parent is obtained.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: Licensing audited 12 children's files. One children's file did not have a record to release a child to someone other than the parent.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure a log is kept for all inspections, maintenance and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 15, 2022
Observations: The Playground checklist was not observed this date. Staff did not know where it was being stored.