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
March 29, 2022
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 that a healthy and safe environment is provided at all times while children are under the supervision of employees.
Corrective Actions Taken By Licensee: Licensee Contact submitted photo documentation to Licensing of new fire extinguisher indicating a service due date of April 2023 on January 28, 2022 via email.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Licensing observed five fire extinguishers of which one had a service due date of April 2021.
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensee Contact submit photo evidence of criminal record checks for two staff completed through CRRA to Licensing via email on February 18, 2022.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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 respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment] is kept.
Corrective Actions Taken By Licensee: Licensee Contact submitted photo documentation to Licensing demonstrating record of implementation of monthly fire drill system and yearly emergency plan practices via email on January 28, 2022.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Licensing observed current record was not kept re: implementation of monthly fire drill system and yearly emergency plan practices.
3070 - CCLR 58(1)(a)
Description: A licensee must keep, for each child requiring extra support, a current care plan showing the following information: the diagnoses relevant to the child’s requirement for extra support, as made by health care professionals
Corrective Actions Required: Ensure for each child requiring extra support, a current care plan is kept showing the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.
Corrective Actions Taken By Licensee: Licensee Contact emailed Licensing a letter on January 28, 2022, indicating communication with the parent. This letter stated that the Epi-Pen was no longer required by child and that it had been returned to the family.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Licensing observed medication stored on site and observed an expired Epi-Pen, unknown to staff. Upon reviewing care plan, there was no diagnosis made by a health care professional and an unclear description as to when or how the Epi-Pen should be administered.
3070 - CCLR 58(1)(a)
Description: A licensee must keep, for each child requiring extra support, a current care plan showing the following information: the diagnoses relevant to the child’s requirement for extra support, as made by health care professionals
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
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 review of care plans at least once each year.
Corrective Actions Taken By Licensee: Licensee Contact emailed Licensing on January 28, 2022, indicating communication with the parent. This letter stated that a care plan was no longer necessary.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Licensing reviewed three children's care plans; of which one had not been reviewed since September 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:
Actions Required By Licensing:
To Be Corrected By:
Observations: