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)
Complaint
December 8, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - 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 health, safety and dignity of person in care, specifically staff demonstrating the skills to carry out the duties assigned. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: between September 19, 2025 and November 7, 2025, Licensee submitted a corrective action plan to Licensing. The staff member was no longer employed at the facility. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2025
Observations: Regarding intake August 12, 2025. Through the investigation process, Licensing determined staff did not demonstrate the skills necessary to carry out the duties assigned.
3030 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of person in care
Corrective Actions Required: Ensure the health, safety and dignity of person in care, specifically ensuring the maximum capacity is maintained. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: between September 19, 2025 and November 7, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Staff were to conduct head counts, and the manager would cross check to ensure maximum group size was not exceeded. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2025
Observations: Regarding intake August 12, 2025. Through the investigation process, Licensing determined that the maximum group size as per Schedule E, which states the maximum group size is 12 was exceeded when the Group Child Care (Under 36 Months) programs combined and had a total of 22 children.
3030 - CCLR 34(2)(a)
Description: Without limiting subsection (1) a licensee must ensure that children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E, (except FCC/IHMACC/REC; child qualified if in age range or within one month (except GCC School Age)).
Corrective Actions Required: Ensure children attending are divided into groups, with each group having no more children than that permitted in per Schedule E. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: between September 19, 2025 and November 7, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The Group Child Care (Under 36 Months) rooms and the Group Child Care (30 Months to School Age) rooms would operate with qualified Infant and Toddler Educators and Educators based on Schedule E. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2025
Observations: Regarding intake August 12, 2025. Through the investigation process, Licensing determined there was one staff (ITE) with six children from 7:45 a.m. to 7:55 a.m. This is not meet the requirement of one Infant and Toddler Educator and one other Educator for 5-8 children for the Group Child Care (Under 36 Months) program.
3030 - CCLR 34(2)(b)
Description: Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Corrective Actions Required: Ensure staff to child ratio is maintained as per Schedule E. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: between September 19, 2025 and November 7, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The Group Child Care (Under 36 Months) rooms and the Group Child Care (30 Months to School Age) rooms would operate with qualified staff as outlined in Schedule E. Qualified staff would be replace Educator lunch breaks. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2025
Observations: Regarding intake August 12, 2025. Through the investigation process, Licensing determined that the staff to child ratios were not maintained when there was one staff (ECE) with thirteen children in the Group Child Care (30 Months to School Age) program and Educator lunch breaks were being covered by a lesser qualified staff.
3030 - CCLR 51(1)(a)
Description: A licensee must ensure that behavioural guidance is appropriate to the age and development of the child who is receiving the guidance,
Corrective Actions Required: Ensure behaviour guidance is appropriate to the age and development of the child receiving guidance. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: between September 19, 2025 and November 7, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The staff member was no longer employed at the facility. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2025
Observations: Regarding intake August 12, 2025. Through the investigation process, Licensing determined staff did not use appropriate guidance when staff moved children from under their arms and when children were being grabbed.
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 a daily attendance record showing the time of arrival and departure is kept for each child. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: between September 19, 2025 and November 7, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Daily attendance would be completed by the Educators and verified by the manager. Staff would sign in children when children arrived and departed from one classroom to another. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2025
Observations: Regarding intake August 12, 2025. Through the investigation process, Licensing determined that the children attending the Group Child Care (Under 36 Months) and Group Child Care (30 Months to School Age) programs did not have arrival and departure times for when the child moved from one program to another.