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
February 16, 2022
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 16, 2022
Observations: Licensing audited seven staff files and observed no evidence of a criminal record check for two separate staff members. During the routine inspection, the Manager was able to produce evidence from the HR Department of the school, of one of the two missing criminal record checks.
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 each employee practices implementing the fire drill system at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 25, 2022
Observations: Licensing observed evidence of only one fire drill, dated October 2021, being completed and recorded on the Fire and Emergency drill record; Licensing also observed, by admission from the Manager, that the fire drills for November and December 2021 and January 2022 had not been practiced.
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 current records are kept of each of the following: (c) a record 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: February 25, 2022
Observations: Licensing observed on the fire and emergency drill record, evidence of only one fire drill being recorded, dated October 2021.
3070 - CCLR 57(2)(b)
Description: A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
Corrective Actions Required: Ensure for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 16, 2022
Observations: Licensing audited eight children's files and observed three registration forms that were each missing the date of enrollment.
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, 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 16, 2022
Observations: Licensing audited 3.5 months of attendance records and observed the following: Eight missing departure times from attendance records dated December 17, 2021, January 1, 13 and 27 2022 and Licensing also observed four missing arrival times on the January 14 2022 attendance record.
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, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 16, 2022
Observations: Licensing audited eight children's files and observed one file was missing the name and telephone number of a medical practitioner.
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: Ensure, 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 16, 2022
Observations: Licensing audited eight children's files and observed one file was missing a photograph or digital image of the child.