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
April 4, 2023
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 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: April 4, 2023
Observations: Licensing observed cleaning products accessible under the sink and a potty seat with feces smeared on it in the Group Child Care (30 Months to School Age) program. Licensing observed staff remove the cleaning products from under the sink during the inspection.
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 all staff have a valid criminal record check on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited nine staff files of which four did not have a criminal record check.
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:
Corrective Actions Taken By Licensee: Ensure all children have character references on file.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited nine staff files of which four were missing 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 record 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: April 18, 2023
Observations: Licensing audited nine staff files of which one was missing a resume.
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 all staff have copies of any diplomas, certificates or other evidence of their training on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited nine staff files of which three were missing copies of any diplomas, certificates or other evidence of their training.
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 all staff have immunization staff on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited nine staff files of which three were missing immunization status.
3010 - CCLR 19(4)(a)
Description: A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry
Corrective Actions Required: Ensure all educators or assistants have their certificates validated through the ECE Registry.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited nine staff files of which one was missing validation from the ECE Registry for their certificate.
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: Ensure all employees implement the fire drill system at least once per month.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing observed a fire drill had not been completed for January or March 2023.
3010 - CCLR 56(1)(b)
Description: A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements]
Corrective Actions Required: Ensure for each employee, records are kept for items required under Section 19(1).
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing observed one staff did not have a file.
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 ratios of employees to children is no less than that as permitted in Schedule E.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 4, 2023
Observations: Licensing observed 16 children with one Early Childhood Educator Assistant (ECEA) and two Responsible Adults (RA) in the Group Child Care (30 Months to School Age) program. One Early Childhood Educator (ECE) and two ECEA's are required for 16 children.
3060 - CCLR 46(1)
Description: A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
Corrective Actions Required: Ensure a program is established to instruct children in and to practice the rules of health and hygiene.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 4, 2023
Observations: Licensing observed children in the Group Child Care (School Age) program did not wash their hands before or after eating snack. Additionally, Licensing did not observe the tables being sanitized after children ate.
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 all children have medical insurance plan number on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited 10 children's files of which one was missing medical insurance 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 all children have date of enrollment on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited 10 children's files of which eight were missing date of enrollment.
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 time of arrival and departure is documented on the attendance records.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 4, 2023
Observations: Licensing observed time of arrivals and departures were not documented on the attendance record in the Group Child Care (School Age) program.
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 all children have name and telephone number of a medical practitioner on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited 10 children's files of which one was missing the name and telephone number of a medical practitioner.
3070 - CCLR 58(2)(a)
Description: The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required: Ensure care plans are developed in consultation with the parent or any parent requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 4, 2023
Observations: Licensing observed two care plans of which one did not indicate it had been developed in consultation with the parents.
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 all care plans are reviewed at least once per year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing audited two care plans of which one had not been reviewed since January 2022.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure a log of all inspections, maintenance & repairs is kept of the outdoor area.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Staff stated they did not keep a log of all inspections, maintenance & repairs of the outdoor area.
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: April 4, 2023
Observations: Licensing observed 26 children in the Group Child Care (School Age) program in the portable. The maximum capacity licensed for the portable is 24.
3080 - CCLR 11(4)
Description: A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.
Corrective Actions Required: Ensure certificates of all assistants and educators are displayed in a prominent place.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2023
Observations: Licensing observed one educator or assistant certificate was not posted this date.