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)
Non-Visit Follow-up
October 13, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - SPS DOLSOP (Inspected)
Description: Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received evidence showing the outdoor check list has been completed daily.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 not to employ a person without first obtaining a valid Criminal Record Check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 26, 2022
Observations: Licensing reviewed 9 of 9 staff files. One file was missing a CRC.
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:
Corrective Actions Taken By Licensee: Licensing received a copy of the missing reference letter from a staff file.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing received an incident report from the Manager for the reportable incident that was not reported to Licensing.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 to keep a record for all children showing: immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 26, 2022
Observations: Licensing reviewed 7 of 31 children's files. 4 were missing record of immunization status.
3070 - CCLR 57(2)(c)
Description: A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure
Corrective Actions Required: Ensure to keep a record for each child, showing daily attendance record indicating for each day
with time of arrival and departure.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 26, 2022
Observations: Licensing observed 6 children in care all in one program. Only 2 children were signed in on the
attendance records, both signed in to different rooms. While on site attendance records were completed and up to
date. New registration forms were created while Licensing was on site so children could be signed in properly to the
room they are present in.
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 in care showing: name and contact number of a medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 26, 2022
Observations: Licensing reviewed 7 of 31 children's files. 2 files were missing doctor's phone numbers, 1 file was missing doctor's name and phone number.
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:
Corrective Actions Taken By Licensee: Licensing received two photos missing from children's files.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCLR 57(2)(j)
Description: A licensee must keep, for each child, a record showing the following information: (j) a record of any person who is not permitted access to the child
Corrective Actions Required: Ensure to keep a record for all children in care showing: any person not permitted access to the
child.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 26, 2022
Observations: Licensing reviewed 7 of 31 children's files. 7 files were missing record of person's not permitted access.
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 care plans at least once a year with a parent/guardian.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 26, 2022
Observations: Licensing reviewed 2 of 2 care plans. Both care plans were not signed or dated by a parent/guardian.