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
November 4, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 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 evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 4, 2022
Observations: Licensing reviewed eight staff files. Three files were missing immunization status.
3010 - CCLR 23(1)(a)
Description: A licensee must ensure that children have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,
Corrective Actions Required: Ensure that children have at all time immediate access to an employee that holds a first aid and CPR certificate, provided on completion of a course that meets the requirements of schedule C.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 4, 2022
Observations: Licensing reviewed eight staff files. Two staff were missing first aid certificates.
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 licensee must keep current records respecting compliance with section 22(2)(b) and (c) [emergency training and equipment].
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 4, 2022
Observations: Licensing observed the 3-5 program had no record of a fire drill being practiced since August. Staff stated that it had been practiced but not recorded.
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 that the ratio of employees to children attending a community care facility 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: November 4, 2022
Observations: Licensing observed upon arrival that the Infant Toddler program had 6 children and one ITE and one RA acting as an ECEA. This was corrected during the inspection. An ECEA, acting as an ECE switched programs with the RA. This brought the program into compliance.
3050 - 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 licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 4, 2022
Observations: Licensing observed the Corrective Action Plan for the Lead in Water was being followed with a two minute flush being done each morning, but the flush was not recorded.
3060 - CCLR 14(4)(a)
Description: A licensee, other than a licensee who provides a care program described as either Preschool (30 months to School Age) or Group Child Care (School Age), must have in a community care facility a sturdy surface for changing diapers, located outside the food preparation area, next to a covered container for soiled clothing
Corrective Actions Required: Ensure licensee must have in the community care facility a sturdy surface for changing diapers, located outside of the food preparation area, next to a covered container for soiled clothing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 4, 2022
Observations: Licensing observed that the diaper change surface in the 3-5 program did not have a covered container next to it.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Enusre a log is kept of all inspections, maintenance & repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 4, 2022
Observations: Licensing observed the daily outdoor checks had not been recorded in November, and some days in October in the Infant Toddler program. There was no record of outdoor checks in the 3-5 program.