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
September 9, 2026
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 16(4)(b)
Description: A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are safely constructed, free from hazards and in good repair.
Corrective Actions Required: Ensure equipment is free of entanglement hazards.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing used the entanglement device to test the composite slide, and detected an entanglement on the edge of the slide. This represents an immediate risk to the health and safety of children and must be corrected immediately. Full compliance will not be achieved until this is corrected. Manager stated the area will not be used by children until corrected.
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 educator or assistant certificates are validated through the ECE Registry.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing audited three staff files. Two files were missing a certificate validated through the ECE Registry.
3010 - CCLR 19(5)(c)
Description: Despite this section, a licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or 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 a record of immunization for volunteer is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing observed an immunization record for volunteer was missing.
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 records of immunization status must be kept for each child's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing audited five children's files. One file did not contain a record of immunization status..
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 attendance records show time of arrival and departure for all children in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing observed four children had not been signed out the attendance on August 10, 2026.
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 ta record of medical practitioner is obtained in each child's file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing audited 5 children files. One file did not obtained a record of medical practitioner.
3070 - CCLR 57(3)(b)
Description: A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.
Corrective Actions Required: Ensure children's files contain a consent to release a child to someone other than parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing audited five children's files. One file was missing a consent to release a child to someone other than parent.
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 a care plan is reviewed at least once a year with parent and any person requested by parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 21, 2026
Observations: Licensing observed a care plan was last updated with parent on February 2025, and the manager was not aware if there were any further updates.