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
January 28, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 a record of the person's work history is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing reviewed two staff files. One file did not contain 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 copies of any diplomas, certificates or other evidence of the person's training is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing reviewed two staff files. Files did not contain evidence of training.
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 is kept respecting compliance with section 22 (2) (b) and (c)[emergency training and equipment].
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing observed a record was not kept of fire drills practiced. Staff stated they had been practicing fire drills but this was not recorded.
3050 - CCLR 48(5)
Description: A licensee must ensure that safe drinking water is available to children.
Corrective Actions Required: Ensure a care plan is developed in consultation with the parent and any person requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 31, 2022
Observations: Licensing observed a record was not kept to verify daily water flushes to remove lead.
3070 - CCLR 57(2)(f)
Description: A licensee must keep, for each child, a record showing the following information:
(f) any medication administered to the child, including the amount and the time at which the medication was administered
Corrective Actions Required: Ensure a record is kept showing the following information for each child: (f) any medication administered to the child, including the amount and the time at which the medication was administered.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 28, 2022
Observations: Licensing observed a signed medication form with no end date or instructions in a child's file. Staff had the medication on site and stated that this medication had been given to the child but not recorded.
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 a record is kept for each child that includes a photograph or digital image and other information that can be used to readily identify the child in an emergency.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing reviewed eight children's files. Two files did not contain a photograph of the child.
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 a care plan is developed in consultation with the parent and any person requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing observed that a child requiring extra support did not have a care plan.
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 the care plan is reviewed in consultation with the parent and any person requested by the parent at least once a year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing observed two care plans that were not reviewed within a year.
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 records referred to in section 56 to 58 are keep in a single place at the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing observed two staff employed at the facility did not have files on site.
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 & repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2022
Observations: Licensing observed a record of play ground checks was not kept. Staff stated they do playground checks daily but had not recorded this information.
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 the license is displayed in a prominent 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: January 28, 2022
Observations: Licensing observed two licenses that were not valid posted in classroom A. This was corrected at the time of inspection.