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
March 18, 2025
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 all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 18, 2025
Observations: Licensing reviewed four staff files. Three files did not contain a criminal record check for the employee.
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 references in respect of the person are obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2025
Observations: Licensing reviewed four staff files. One file did not contain two character references.
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 immunization status is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2025
Observations: Licensing reviewed four staff files. One file did not contain immunization status.
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 a record is kept for each child showing immunization status, medical insurance plan number and sex.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2025
Observations: Licensing reviewed six children's files. One file did not contain a medical insurance plan number, six files did not indicate the sex of the child and one file did not contain immunization status.
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 a record is kept for each child showing the name and contact number for a medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2025
Observations: Licensing reviewed six children's files. Two files did not contain a medical practitioner.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure a log is kept of all outdoor play area inspections, maintenance and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 18, 2025
Observations: Licensing observed that a log was not kept of outdoor area safety checks.
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 children in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 18, 2025
Observations: Licensing observed twenty four children were in care in Class A. Maximum capacity of Class A is eighteen children.