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 8, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 of the yearly emergency plan is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 5, 2025
Observations: Licensing observed a record of the yearly emergency plan was not kept. Licensing observed the last record of the yearly emergency plan was on October 2023. Staff stated they had practiced the earthquake drill on October 2024, but did not find the record.
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 medical insurance plan number 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: December 5, 2025
Observations: Licensing audited seven children files. One file did not contain medical insurance plan number.
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 record is kept for daily attendance with times of arrival and departure.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 5, 2025
Observations: Licensing observed three children had not been signed out the attendance on August 26, September 4, and September 12, 2025.
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 containing a medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 5, 2025
Observations: Licensing audited seven children's file, one file was missing a record of a medical practitioner.
3070 - CCLR 57(3)(a)
Description: A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached,
Corrective Actions Required: Ensure all children's files contained record of written consent to call an ambulance in case of accident/ illness if parent cannot immediately be reached.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 5, 2025
Observations: Licensing audited seven children's files and observed one missing record of written consent from parent to call an ambulance in case of accident/ illness if parent cannot immediately be reached.
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: December 5, 2025
Observations: Licensing audited seven children's files. One file was missing a consent to release a child to someone other than parent.