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
May 3, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 47
Description: A licensee, other than a licensee who provides a care program described as School Age Care on School Grounds, must ensure that any heated water accessible to children is heated to no more than 49° Celsius.
Corrective Actions Required: Ensure person in care do not have access to water greater than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 3, 2024
Observations: Licensing measured the bathroom sink temperature and had water readings between 55.5 and 55.9 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. Staff turned off the hot water during the inspection and stated it would not be turned on until Licensing could return to reassess. Full compliance will not be achieved until the plan has been implemented and completed.
3000 - SPS DOLSOP (Equipment height)
Description: Height of equipment – Highest play surface as reported by Licensee or observed by LO: for toddlers (12 to 36 months) no more than .9 metres (3 feet) for preschool children (30 months to school age, no more than 1.5 metres (5 feet) for school-age children (attending school) no more than 2.3 metres (7 feet)
Corrective Actions Required: Ensure the height of the equipment for preschool children (30 Months to School Age) is not more than 5 feet.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing observed a climber in the outdoor area that measured 5.2" not meeting the DOLSOP requirements of no more than 5 feet for preschool children (30 Months to School Age)
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 a criminal record check is obtained for employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing audited four staff files and one file did not contain a criminal record check.
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 employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing audited four staff files and observed three files did not contain character references for employees. Licensee obtained two character references for two staff during the Inspection.
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 evidence of compliance with Province's immunization control programs is obtained for employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing audited four staff files and observed two files did not contain evidence of immunization status for employees.
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 educators or assistants certificates are verified through the ECE BC Registry.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing observed three staff certificates were not verified.
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 is notified within 24 hours if a child has 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: May 17, 2024
Observations: Licensing inspected the minor incident log book and observed there was a reportable incident on April 23, 2024 that was not notified within 24 hours to the Medical Health Officer.
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 contain a record showing immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing audited six children's files and observed two files did not contain 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 the children's files contain a record showing a medical practitioner and emergency contacts.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing audited six children's files and two did not contain a medical practitioner and one file did not contain emergency contacts.
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 care plans are reviewed at least once a year with parents and any person requested by parents.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing observed one care plan was not reviewed at least once a year. Date April 2023.
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 Sections 56-58, facility records and staff records are kept in a single place at the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing observed three staff files and emergency drills records were not kept in the facility. Licensee stated she had the documents in another place.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure a log of all inspections, maintenance and repairs is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing observed a log for all inspections, maintenance and repairs was not recorded on May 2, 2023.
3080 - CCLR 11(4)
Description: A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.
Corrective Actions Required: Ensure certificates or copy of certificates of any educator/assistant employed is displayed in a prominent place.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 17, 2024
Observations: Licensing observed that two certificates of two educators employed were not displayed in a prominent place.