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
October 24, 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 a health and safe environment at all times.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing observed the fire extinguisher over due for servicing.
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 that children do not have access to any object that may be hazardous.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 31, 2022
Observations: Licensing observed a large tv not fixed to the wall.
3000 - SPS DOLSOP (Inspected)
Description: Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded
Corrective Actions Required: Ensure to keep a log of all daily inspections.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing observed the outdoor checklist not completed from October 17-24
3010 - CCALA 7(1)(d)
Description: A licensee must appoint a manager for the community care facility.
Corrective Actions Required: Ensure to appoint a manager for the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 24, 2022
Observations: Licensing observed no manager for the facility.
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 not to employ a person until obtaining record of work history.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing reviewed 2 of 2 staff files on site. One file was missing a resume.
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: Ensure that each employee practices implementing the fire drill system monthly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 14, 2022
Observations: Licensing observed no Fire Drill completed in the month of September.
3010 - CCLR 29(c)
Description: To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,
Corrective Actions Required: Ensure responsible adults have completed a course/combination of courses of at least 20 hours.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing reviewed 2 of 2 staff files on site. One file was missing record of 20 hours of training for
responsible adult status.
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 to keep current records of staff files are current.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 31, 2022
Observations: Licensing observed four staff who work at the facility with no staff files on site. Two of the staff were
working at the time of the inspection.
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 current records show date and time of arrival and departure.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing observed 14 times in the past two weeks where children were not signed out with a time of
departure. Licensing also observed attendance records are not dated.
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 to keep a record for each child showing name and telephone number of medical
practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing reviewed 7 of 21 children's files. One file was missing Dr. phone number.
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 care plans at least once each year with the parent/guardian.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 18, 2022
Observations: Licensing reviewed 3 of 3 care plans. All three hadn't been reviewed in the past year.
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 to operating the community care facility in a manner that will promote the health, safety
and dignity of children in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing observed the Lead in Water corrective actions not being documented. Staff stated the 2 min
water flush is completed every morning.
3080 - CCLR 11(1)
Description: A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Corrective Actions Required: Ensure to display the facility Licence in a prominent place.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing observed the facility Licence not posted on site.