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
June 8, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCLR 13(1)
Description: A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees
Corrective Actions Required: Ensure that fire extinguishers are serviced annually.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing observed two fire extinguishers that had been last serviced on May 16, 2021 and May 21, 2021.
3000 - SPS DOLSOP (Entanglement)
Description: Equipment is free of entanglement hazards in areas of uncontrolled motion. (Something around the child’s neck becomes caught on equipment)
Use Entanglement test device
Corrective Actions Required: Ensure that all indoor and outdoor play materials and equipment accessible to children are free from hazards.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: This item is a carry over from Routine Inspection ALAN-BV4Q7H dated November 5, 2020 regarding the fire pole. On this date, June 8, 2022 Licensing detected an entanglement on the fireman's pole using the entanglement device. This represents an immediate risk to the health and safety of children in care and must be corrected immediately. Manager stated that the children will not use the fireman's pole until the entanglement can be repaired and approved for use by Licensing.
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 a current criminal record check is kept on file for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing audited six staff files and two files were missing a criminal record check.
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 a work history is kept on file for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing audited six staff files and one file was missing a work history.
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 immunization status is kept on file for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing audited six staff files and one file was missing their immunization status.
3010 - CCLR 19(5)(a)
Description: Despite this section, a licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or 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 volunteers have a current criminal record kept on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing observed a volunteer who was present and did not have a criminal record check on file.
3010 - CCLR 19(5)(b)
Description: Despite this section, a licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following: character references in respect of the person
Corrective Actions Required: Ensure that character references are kept on file for volunteers.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing observed a volunteer who was present and did not have character references on file.
3010 - CCLR 19(5)(c)
Description: Despite this section, a licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or 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 immunization status are kept on file for volunteers.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing observed a volunteer who was present and did not have immunizations status on file.
3010 - CCLR 29(c)
Description: To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,
Corrective Actions Required: Ensure that all staff have completed a course, or a combination of course, of at least 20 hours duration in child development, guidance, health and safety, or nutrition.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: This item is a carry over from ALAN-BV4Q7H dated November 5, 2020 regarding an employee must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition.
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 that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing observed a unsupervised child enter the facility from the playground. The playground is across the street from the physical facility.
3050 - CCLR 48(5)
Description: A licensee must ensure that safe drinking water is available to children.
Corrective Actions Required: Ensure that the lead in water corrective action plan is being followed and that the water flushes are bring documented.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing observed that the water flushing log had not been completed since October 2021. Licensee stated that the school had corrected the lead in the water, however she still practiced flushing the water.
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 that current records for each child shows the date of enrolment.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing audited five children's files and two files were missing date of enrollment.
3090 - 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 that the lead in water corrective action plan is being followed and the community care facility operates in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 21, 2022
Observations: Licensing observed that the water flushing log had not been completed since October 2021. Licensee stated that the school had corrected the lead in the water, however she still practiced flushing the water.