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
April 15, 2025
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 that each employed person in a community care facility has obtained a criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that a staff file was missing a valid criminal record check.
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: Ensure that each employee has proof of at least two receieved and/or check character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that one staff file was missing a character reference.
3010 - CCLR 19(1)(c)
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 record of the person’s work history
Corrective Actions Required: Ensure that each staff file has a copy of their work history/resume.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that one staff file was missing evidence of work history/resume.
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 that each staff file contains copies of certificates and training.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that one staff file was missing evidence of responsible adult training.
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 that each staff file contains immunization declaration.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that 2 staff files were missing immunization declarations.
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 that children's files contain MSP numbers and immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that 2 files were missing MSP numbers and 3 files were missing immunization status.
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 that, in case of emergency, all children's files contained a photo.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that one child's file was missing a photo.
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 that each of the children's files contain a record of "persons not permitted"
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2025
Observations: Licensing observed that all files are missing a record showing information for "persons not permitted"