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
January 20, 2023
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: Ensure 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 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: February 20, 2023
Observations: Licensing reviewed six staff files. Two files were missing 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 licensee must keep current records of implementation of yearly emergency plan practices.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2023
Observations: Licensing observed an emergency drill had not been recorded in the previous year. Staff stated an emergency drill was practiced summer 2022.
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 a licensee must keep, for each child, a record showing medical insurance plan numbers and immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2023
Observations: Licensing audited ten children's files. Three files were missing MSP numbers and three files were missing immunization records.
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 licensee must keep, for each child, a record showing the name and number of a medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2023
Observations: Licensing audited ten children's files. Two files were missing name of a medical practitioner and three files were missing medical practitioner numbers.
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 licensee must keep, for each child, a record showing a photograph or digital image of the child.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2023
Observations: Licensing audited ten children's files. One file was missing a photo or digital image of the child.
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 licensee must develop the care plan in consultation, with a parent of the child requiring extra support and any other person requested by the parent.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2023
Observations: Licensing observed two children with medications (inhaler and epi-pen) did not have a care plan.
3070 - CCLR 59(a)
Description: In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58,
Corrective Actions Required: Ensure licensee must keep in a single place at the facility records referred to in Sections 56-58 (staff records).
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2023
Observations: Licensing observed the staff files were not at the facility. Licensee contact stated that they were at her home for review.
3070 - SPS DOLSOP (Log Kept)
Description: Log kept of all inspections, maintenance & repairs
Corrective Actions Required: Ensure log is kept of all inspections, maintenance & repairs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2023
Observations: Licensing observed daily outdoor checks had not been documented in January 2023.