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
April 4, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 to obtain character references for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2025
Observations: Licensing audited 11 staff files. One staff file was missing a record of character references.
3050 - CCLR 48(5)
Description: A licensee must ensure that safe drinking water is available to children.
Corrective Actions Required: Ensure safe drinking water is available to children at all time.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2025
Observations: Licensing observed no record of the two minute flush at the beginning of the day since April 1, 2025 as stated in the corrective action plan.
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 showing the name and telephone number for a medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2025
Observations: Licensing reviewed 12 children's files. Three files did not contain the name and telephone number for 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: May 5, 2025
Observations: Licensing audited 12 children's files and observed one missing record of written consent from parent to call medical practitioner or ambulance in case of accident/ illness if parent cannot immediately be reached.
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 to review the child's care plan with the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By: May 5, 2025
Observations: Licensing audited 12 children's files. One child's care plan was not reviewed at least once a year with a parent.
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 5, 2025
Observations: Licensing observed a log of all inspections, maintenance and repairs was not kept after March 27, 2025.
3080 - 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 to operate the community care facility in a manner that will promote the health, safety & dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2025
Observations: Licensing observed a corrective action plan for lead in water was not followed. Staff stated they flushed the water for two minutes but did not record it.
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 certificate or copy of the certificate of any educator/assistant employed 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 5, 2025
Observations: Licensing observed one ECE's certification was not displayed in a prominent place.