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 18, 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 that all staff files contain a criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 8, 2023
Observations: Licensing audited two staff's files and one staff file was missing a criminal record check. The staff file contained a criminal record check from another organization.
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 that all staff files contain a record of immunization.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 8, 2023
Observations: Licensing audited two staff files and one file was missing a record of immunization.
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 that all staff certificates are verified through the early childhood educator registry.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 8, 2023
Observations: Licensing audited two staff files and one staff file was missing verification of certificate.
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required: Ensure that each employee practices implementing the fire drill system at least once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 8, 2023
Observations: Licensing observed that the October fire drill had not practiced.
3010 - CCLR 22(2)(c)
Description: A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
Corrective Actions Required: Ensure that employees practice a emergency drill at least once a year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 8, 2023
Observations: Licensing observed that the emergency drill had not been practiced.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure that 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: November 8, 2023
Observations: Licensing observed that the outdoor log of inspections, maintenance and repairs for October 2-6 and 9-12, 2023 was not kept.
3080 - 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 that the Medical Health Officer is notified of changes in the information provided in section 9.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 8, 2023
Observations: Licensing observed that the outdoor play space entrance was blocked and there was construction material on the ground and surrounding one of the doors to the facility. Staff stated that the outdoor play space was not being used during the time of construction.
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 that all employed staff certificates are displayed in a prominent place.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 8, 2023
Observations: Licensing observed that a staff's certificate that was employed was not displayed in a prominent place.