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
December 11, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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 thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 29, 2026
Observations: Licensing observed daily play space inspections had occurred, however, between December 8 and December 10, 2025, daily inspections were not recorded.
3010 - CCLR 19(1)(d)
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: copies of any diplomas, certificates or other evidence of the person’s training and skills
Corrective Actions Required: Ensure a person is not employed 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: copies of any diplomas, certificates or other evidence of the person's training and skills.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 29, 2026
Observations: Licensing audited nine staff files. Two staff files did not have a copy of any diplomas, certificates or other evidence of the person's training and skills.
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 a person is not employed 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 29, 2026
Observations: Licensing audited nine staff files. On staff file did not have evidence of immunization status.
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 a current record is kept respecting compliance with emergency training and equipment.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 29, 2026
Observations: Licensing observed that fire drills were practiced monthly, however, there was no record of fire drills in September and November 2025.
3070 - CCLR 55(1)(a)
Description: A licensee must immediately notify a parent or emergency contact if, while under the care or supervision of the licensee, the child becomes ill or is injured,
Corrective Actions Required: Ensure that a parent or emergency contact is immediately notified if while under the care or supervision of the Licensee, the child becomes ill or injured.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 29, 2026
Observations: Licensing observed several minor incidents in the minor incident log where a parent or emergency contact was not notified when a child was injured.
3070 - CCLR 58(2)(a)
Description: The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required: Ensure care plan(s) are developed in consultation with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 29, 2026
Observations: Licensing observed six care plans. Three care plans did not have evidence that a parent of the child requiring extra support had been consulted regarding the care plan.