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)
Follow-Up
September 18, 2025
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:
Corrective Actions Taken By Licensee: Licensing audited six staff files. Immunization status had been obtained for all staff files.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 ECE certificates had been verified by the ECE Registry.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 26, 2025
Observations: Licensing observed one staff ECE certificate had not been verified by the ECE Registry.
3010 - CCLR 56(1)(b)
Description: A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements]
Corrective Actions Required: Ensure staff files are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 25, 2025
Observations: Licensing observed one staff file was not at the facility.
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 Schedule E is maintained for staff to child ratio.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 12, 2025
Observations: Licensing observed the two Group Child Care (Under 36 Months) programs had the following staffing: In the Infant program there were three staff (ITE, ECEA, ECEA) with eleven children and in the Toddler program, there were three staff (ITE, ECEA, ECEA) with nine children inside. Both programs did not meet Schedule E where an ITE, ECE, ECEA was required for nine children and for eleven children.
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 audited seven children's files. A digital photo had been obtained for the children's files.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: