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
June 9, 2021
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 13(1)
Description: A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees
Corrective Actions Required: Ensure a healthy and safe environment is provided at all times.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2021
Observations: The fire extinguisher was due for servicing on May 31, 2021.
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: June 9, 2021
Observations: Licensing observed the following hazards indoors: Thumb tacks accessible in a drawer and multiple exposed electrical outlets. Licensing observed the following hazards outdoors: lawn mower accessible and animal excrement in the outdoor play area. Staff moved the thumb tacks from the drawer, covered all except one exposed outlet and removed the lawn mower from the outdoor play area during the inspection.
3000 - SPS DOLSOP (Hard surfaces)
Description: Equipment must not be installed over concrete, asphalt or other hard surfaces (may include dry grass
Corrective Actions Required: Ensure equipment is not installed over concrete, asphalt or other hard surfaces (may include dry grass).
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2021
Observations: The Little Tikes slides were installed over hard, compact dirt. Staff stated there used to be grass there that became dried up.
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 proof of character references on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2021
Observations: Two staff files audited; one was missing proof of 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 copy 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: June 30, 2021
Observations: Two staff files audited; one was missing copy of a resume.
3020 - CCLR 22(3)
Description: A licensee must display a copy of the fire drill system in a prominent place in the community care facility.
Corrective Actions Required: Ensure a copy of the fire drill system is displayed in a prominent place.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2021
Observations: A copy of the fire drill system was not displayed. Staff corrected during inspection.
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 monthly fire drills is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2021
Observations: Monthly fire drill record was blank. Staff stated fire drills had been conducted each month but the fire drill record was destroyed by something that leaked on it.
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: June 9, 2021
Observations: There were eight children in care; five of the children were under 48 months old.
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 all children in care have a file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2022
Observations: One child in care did not have a 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 children have sex and immunization status on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2021
Observations: Six files audited; four were missing sex and one was missing immunization status.
3070 - CCLR 57(2)(c)
Description: A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure
Corrective Actions Required: Ensure times of arrival and departure is recorded on the daily attendance.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2021
Observations: Daily attendance records for children did not indicate some times of departures.
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 children have a photograph or digital images on file to readily identify them in an emergency.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2021
Observations: Six files audited; four were missing a photograph or digital image of the child to readily identify them in an emergency.
3070 - CCLR 57(2)(k)
Description: A licensee must keep, for each child, a record showing the following information: (k) the date on which the child stops attending the community care facility.
Corrective Actions Required: Ensure for children who no longer attend the facility that the date on which the child stopped attending is recorded.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2021
Observations: Files for children who no longer attend the facility did not indicate the date on which the child stopped attending.
3070 - CCLR 57(3)(a)
Description: A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached,
Corrective Actions Required: Ensure children have written consent to call a medical practitioner or ambulance in case of accident or illness on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2021
Observations: Six files audited; four were missing written consent to call a medical practitioner or ambulance in case of accident or illness.
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 all records referred to in sections 56 to 58 are kept in a single place in the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2021
Observations: Staff was unable to find the log of minor accidents, illnesses and unexpected events for Licensing to review.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure a log is kept of all inspections, maintenance and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2021
Observations: The log of all inspections, maintenance and repairs was blank. Staff stated the record was destroyed from something that leaked on it.
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: June 9, 2021
Observations: Licensing observed eight children in the facility. This exceeded the maximum capacity allowed of seven for Family Child Care. Staff stated one of the children was not normally present. The child left with an adult resident during the inspection.
3080 - CCALA 7(1)(c)
Description: Licensee must display licence in the prescribed manner
Corrective Actions Required: Ensure the licence is displayed in the prescribed manner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2021
Observations: The licence was not displayed in the facility. Staff corrected during inspection.
3080 - CCLR 10(1)
Description: Applicants for licences and licensees must notify a medical health officer immediately of any change in the information provided under section 9
Corrective Actions Required: Ensure a medical health officer is notified immediately of any change in information provided under section 9.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2021
Observations: The nap room/playroom had been changed into an office area. This was not part of the original application.