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 22, 2023
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 all staff files have CRC's through the CRRA.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited seven staff files and observed two missing Criminal Record Checks.
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 character references are obtained for all staff files.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited seven staff files and observed one missing two character references and one missing one character reference.
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 has been obtained for all staff files.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited seven staff files and observed six missing immunization status.
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 ratio of employees to children is no less than that permitted in Schedule E.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing observed one ECE bumping up for an absent ITE and two ECEA's in one of the Group Child Care (Under 36 Months) at the time of inspection.
3040 - CCLR 53(1)(a)
Description: If a licensee has agreed with a parent to give a child any medication prescribed by a medical practitioner or provided by the parent, the licensee and his or her employees must ensure that the medication is (a) administered to the child in the amount and at the times specified by the child’s parent or in the child’s record or care plan
Corrective Actions Required: Ensure medication is administered in amount and at times specified by parent/child's record.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing observed a child's medicine form did not have amount and times specified by parent or child's record.
3070 - CCLR 10(1)
Description: Applicants for licences and licensees must notify a medical health officer immediately of any change in the information provided under section 9
Corrective Actions Required: Ensure Licensee notifies MHO immediately of any change in information under section 9 (daily outdoor play provided in accordance with documents submitted with application such as offsite plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 22, 2023
Observations: Licensing observed the approved offsite playground was not being used. The park had a sign stating that the park was closed due to flooding. Licensing did not receive notification that the approved offsite play space was closed. City workers stated that the park had been closed for approximately three weeks.
3070 - CCLR 55(2)(a)
Description: A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee,
Corrective Actions Required: Ensure MHO notified within 24 hours if child has been involved in/may have been involved in a reportable incident described in Schedule H.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 23, 2023
Observations: Licensing observed in the communication log that on March 15, 2023 the third floor had a gas leak and staff smelt gas in the facility and had to leave until they were told they could return. No incident was reported to Licensing.
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 all children's files have immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 23, 2023
Observations: Licensing audited five children's files and observed one missing 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 all children's files have medical practitioner name and telephone number and emergency contact.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 23, 2023
Observations: Licensing audited five children's files and observed one missing medical practitioner name and telephone number and one missing emergency contact.
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 all children's files have photo of child to readily identify child in an emergency.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited five children's files and observed five files did not have photo/digital image of child or other information to readily identify child in an emergency. Staff stated they did not have any photos of the children.
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 and repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing observed the facility had not been keeping a log of the outdoor inspections.
3090 - AP DOLSOP (Outdoor Active Play)
Description: Outdoor Active Play General Minimum of 60 minutes of outdoor active play provided (applies to FCC, IHMACC, MACC, GCC (Under 36 mos), GCC (30 mos to SA), GCC (SA) [weather and/or space permitting]
Corrective Actions Required: Ensure children get a minimum of 60 minutes of outdoor active play.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing observed the children in one of the Group Child Care (Under 36 Months) were spending the outdoor time in strollers. Staff stated that they take the children for walks daily as they do not have use of the outdoor play space.