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 23, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 47
Description: A licensee, other than a licensee who provides a care program described as School Age Care on School Grounds, must ensure that any heated water accessible to children is heated to no more than 49° Celsius.
Corrective Actions Required: Ensure that any heated water accessible to children is heated to no more than 49° Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing tested the water temperature at 56° Celsius for one washroom sink and at 55° Celsius for a second washroom sink. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Manager sated staff will supervise children as they wash their hands and notified the school to request the water temperature be turned lower. Full compliance will not be achieved until the plan has been implemented and completed.
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 criminal record check is obtained for a person employed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 23, 2023
Observations: Licensing audited three staff files, one file was missing a 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 character references are obtained for a person employed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited three staff files, one was missing character references.
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 evidence of training is obtained for a person employed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing observed that evidence of training had not been obtained for a Responsible Adult.
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 record of immunization status is kept for a person employed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited three staff files, two files were missing a record of immunization status.
3010 - CCLR 22(2)(b)
Description: A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
Corrective Actions Required: Ensure a fire drill is implemented at least once per month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing observed that a fire drill had not been practiced for the month of December 2022.
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 showing compliance with section 22(c).
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing observed that a record had not been kept if the emergency plan implemented within the last year.
3030 - CCLR 39(1)
Description: A licensee must ensure that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.
Corrective Actions Required: Ensure children are supervised at all times by a person who is an educator, an assistant or a responsible adult or a supervision plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing observed that children repeatedly left the room alone and entered a storage room on multiple occasions without supervision of any of the staff present. The Licensee stated this was not permitted. Staff were not able to hear or see the children and Licensing observed that the staff did not check on the children.
3070 - CCLR 56(1)(f)
Description: A licensee must keep current records of each of the following: (f) a log of minor accidents, illnesses and unexpected events involving children, that did not require medical attention and were not reportable incidents described in Schedule H.
Corrective Actions Required: Ensure a minor incident log is kept current.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing observed that a minor incident log had not been kept current.
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 record is kept for each child showing a medical insurance plan number.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited seven children files, one file was missing a medical insurance plan number.
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 a record is kept, for each child 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 24, 2023
Observations: Licensing observed that the time of departure had not been recorded for all children in care on February 21, 2023.
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 a record is kept for each child showing name and telephone number of medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited seven children's files, one file was missing name and telephone number of 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 a record is kept showing a photo or digital image for children in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited seven children's files, one file was missing a photo or digital image of a child.
3070 - CCLR 58(2)(b)
Description: The licensee must review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Corrective Actions Required: Ensure a care plan is reviewed at least once each year 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: March 24, 2023
Observations: Licensing observed that a care plan for a child who required extra support had last been reviewed with a parent on October 29, 2020.
3080 - CCLR 11(1)
Description: A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Corrective Actions Required: Ensure the facility Licence is displayed in a prominent place at the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Upon arrival Licensing observed that the facility Licence had not been displayed in a prominent place. Corrected at time of inspection.