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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SREL-AX2PNC

FACILITY NAME
Willowbrook Montessori Child Care Centre
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
DCON-77PRS9
FACILITY ADDRESS
20317 67th Ave
FACILITY PHONE
(604) 533-5469
CITY
Langley
POSTAL CODE
V2Y 1P6
MANAGER
Wei Wang

INSPECTION DATE
March 20, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
09:00 AM
DEPARTURE
01:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Child care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSOP).
Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.

The following areas were reviewed:
Licensing
Physical Facility
Staffing
Policies and Procedures
Care and supervision/Hygiene and medication
Nutrition
Program
Child Records and reporting

As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy is provided to the facility.
The Risk Assessment includes any non-compliance identified during the routine inspection and a 3 year ‘historical’ review of the facility’s compliance and operation and is used to determine inspection frequency.

Visit the CCFL website at http://www.fraserhealth.ca/childcare
for additional resources, and links to the Legislation (CCALA and CCLR)
Useful websites to consider:
Regulations and Act at www.health.gov.bc.ca/ccf
Criminal Records Checks at www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
Healthlink BC at https://www.healthlinkbc.ca/hlbc/files/documents/healthfiles/hfile69e.pdf
At time of this inspection all areas inspected were found to be in compliance with the exception of those noted below:

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11010 - CCLR s.13(1) - A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.
Observation: In nap room for Toddler 1 there was an electrical cord for cassette player was dangling from a shelf and posed a risk of injury to children and it is noted staff do not stay in the nap room once children have fallen asleep. In the larger side outdoor play area the cover for sandbox is cracked and poses a risk of injury from a fall if any child stepped on it.
Corrective Action(s): Please ensure a healthy and safe environment for children at all time. Licensing notes the electrical cord was removed during the inspection.
Date to be Corrected: March 27,2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11330 - DLSOP Safe Play Space (materials & equipment [b5]) - [bullet 5] Equipment for toddlers must be no more than 0.9 meters (three feet) in height.
Observation: There is a slide structure in the Toddler play area outside which measures 4 feet 2 inches in height. and does not meet requirements with Director of Licensing Standard of Practice forSafe Play Space.
Corrective Action(s): Please ensure all play equipment meets requirements.
Date to be Corrected: March 27,2018

STAFFING: 12040 - CCLR s.19(1)(a) - 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) a criminal record check for the person.
Observation: Review of staff files indicated current Criminal Record Checks (CRC) were missing for 2 staff and consents are on file indicating they have been requested. There is a system in place for monitoring staff file documentation and staff plan ensures these staff do not work alone.
Corrective Action(s): Discussion took place with the Manager regarding ensuring all staff screening documentation is complete prior to employment of staff.
Date to be Corrected: March 27,2018

STAFFING: 12140 - CCLR s.19(4)(a) - A licensee must not employ a person in a community care facility as (a) an educator or an assistant unless the person holds a certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry,
Observation: Total of 7 staff files were reviewed and verification record was missing for 5 staff who have ECE or ECE Assistant Certificates.
Corrective Action(s): Manager was not aware of the requirement for verification of qualification (ECE, Infant Toddler Certificate, and ECE Assistant) Certificates. Manager made aware of the requirement and process for verifying certificates.
Date to be Corrected: March 27,2018

CARE AND/OR SUPERVISION: 14020 - CCLR s.34(2)(a) - Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.
Observation: Child in Toddler 1 exceeds age requirement of the care program.
Corrective Action(s): Discussion with Manager indicated there was a plan in place to ensure child is in age appropriate care program. Manager made aware if this plan can not be implemented immediately then an application for Temporary Retention must be submitted to Licensing.
Date to be Corrected: Immediately

CARE AND/OR SUPERVISION: 14060 - CCLR s.39(1) - A licensee must ensure that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.
Observation: When children are napping in nap room in Toddler 1 the staff conduct intermittent checks of the napping children once all children have fallen asleep. However, Licensing notes the washroom is accessible from the nap room and the current intermittent supervision practice is not adequate for ensuring the health and safety of children.
Corrective Action(s): Please ensure supervision is maintained of children at all times, including nap time as discussed.
Date to be Corrected: Immediately

PROGRAM: 18060 - CCLR s.44(3)(4)(5) - A licensee, other than a licensee providing a care program described as Occasional Child Care, must provide each child with daily outdoor play periods unless weather conditions would make it unreasonable to do so. (4) Despite subsection (1), a licensee who provides a care program described as Occasional Child Care need not provide a program of outdoor activities.
(5) Despite subsection (3), that subsection applies to a licensee who provides a care program described as Child-minding only if the program provides care for 3.5 hours or more each day.
Observation: Licensing observed 2 children did not go outside with the rest of the children from the Toddler 2 program. Records indicate there were written instructions for one child for one child, however not for the other.
Corrective Action(s): Discussion took place with the staff and Manager regarding requirements for daily outdoor play for all children.
Date to be Corrected: March 27,2018

RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - 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.
Observation: Review of attendance records indicate child arrival and departure, however there was one child who was signed into Toddler 3 and moved to Toddler 1 room but the attendance record does not reflect this change.
Corrective Action(s): Discussion took place with the staff regarding ensuring attendance records being up-dated anytime a child leaves a program room for another room to ensure all children will be accurately accounted for in case of an emergency.
Date to be Corrected: March 27,2018

RECORDS AND REPORTING: 19100 - CCLR s.57(2)(d) - A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Observation: Fouteen registration records were reviewed and Dr.'s name and number was missing for one child.
Corrective Action(s): Please complete records as per requirements.
Date to be Corrected: March 27,2018

RECORDS AND REPORTING: 19200 - CCLR s.57(3)(b) - A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.
Observation: Fourteen records reviewed for children and an alternate pick up person was not indicated for 2 children other than a parent.
Corrective Action(s): Please ensure all records are complete for children and if no alternative person is available then please ensure documentation indicates this information.
Date to be Corrected: March 27,2018


Comments

The Manager was on site to assist with this inspection.
--Staff to child ratio met compliance with regulations
--Programming is posted and available for parent review via a notice board and is Montessori based.
--Licensing observed Staff engaged with children and staff used appropriate language and guidance techniques.
--Licensing observed the children were provided with opportunity for outdoor play from all program rooms with the exception noted above. Some children were provided with opportunity for active play in the gym. Children were observed engaged in a variety of activities, including individual Montessori work, free play, circle, and snack time

Discussions with the Manager:-
-- Staff verification process and requirement
-- Temporary Placement process and requirement

-- New policies for Active Play and Screen Time have been completed and added to the parent handbook, and Manager stated that parents are notified of changes via newsletter to review facility up-dates on website.
A response in writing is required to be submitted to Licensing by the date below, outlining how the contravention(s) have been addressed.

This inspection report was reviewed with the Manager
If you have any concerns or further questions regarding the content of this report, please contact your Licensing Officer. (Contact details provided)
Thank you for your time today

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.