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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CLAN-C4WR7M

FACILITY NAME
Pomegranate Childcare
SERVICE TYPES
301 Group Child Care (under 36 months)
FACILITY LICENSE #
NGIL-AKNMVX
FACILITY ADDRESS
7289 Gray Ave
FACILITY PHONE
(778) 885-6311
CITY
Burnaby
POSTAL CODE
V5J 3Z1
MANAGER
Xiao Jun Xu

INSPECTION DATE
July 09, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
02:35 PM
DEPARTURE
05:05 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 (DLSP). All care categories were inspected for compliance.

Contraventions
Previous Inspection - Not Applicable
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: During the inspection Licensing observed the following:

-the garage door was unlocked. A car was accessible to the children. This is a repeat contravention from inspection # CLAN-BAWVBY.
- lights were hanging at a low level. This is a repeat contravention from inspection #CLAN-B44PS9
Corrective Action(s): Please ensure a healthy and safe environment is provided at all times.
Date to be Corrected: July 12, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11020 - CCLR s.13(2) - A licensee must ensure that the community care facility and the furniture, equipment and fixtures within it are clean and in good repair while children are in attendance.
Observation: During the inspection licensing observed the following in the facility:

-the bathroom sink was fitting loosely in a cabinet
-baseboards with paint chips. This is a repeat contravention from inspection # CLAN-BNVSKN
-Several mats on the floor had puncture marks. These marks could potentially harbour bacteria.
Corrective Action(s): Please ensure the facility is in good repair.
Date to be Corrected: July 28, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11180 - CCLR s.16(4)(a) - A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (a) suitable for the age and development of the children.
Observation: Licensing observed the following in the outdoor play area:

-a two wheeled bicycle
-a small swing set
Corrective Action(s): Please ensure play materials and equipment are suitable for the age and development of children.
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11200 - CCLR s.17 - A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child.
Observation: Licensing observed the following in the outdoor play area:

-a door under the deck was open and contained several paint cans
-A rusty tool was located on he ground within easy reach. Rust can present a potential health hazard.
-One plastic bag and one plastic piece of bubble wrap was located on the ground. This could present as potential choking hazard.
Corrective Action(s): Please ensure children do not have access to any objects or substances that are hazardous to their health and safety.
Date to be Corrected: July 12, 2021

STAFFING: 12200 - CCLR s.22(2)(c) - A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.
Observation: In discussion with the Manager she stated that she did not practice the emergency plan for the year with the children.
Corrective Action(s): Please ensure the emergency plan is implemented annually and that this is documented to comply with the legislation.
Date to be Corrected: July 28, 2021

POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must have all of the following: (b) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: Licensing observed that the fire extinguisher did not have a tag indicating it had been serviced annually. Upon review of the fire extinguisher it was noted that the fire extinguisher was stamped as being produced in 2019. The extinguisher was observed as being within the area of fully charged.
Corrective Action(s): Please ensure that you have an emergency plan to be prepared, to mitigate and to be able to respond in an emergency.
Date to be Corrected: July 28, 2021

RECORDS AND REPORTING: 19080 - CCLR s.57(2)(b) - A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Observation: Five children's records of nine were reviewed. Two children's records were missing a date of enrollment.
Corrective Action(s): Please ensure children's records are complete.
Date to be Corrected: July 28, 2021


Comments

At the inspection dated July 9, 2021 there were 6 children, and 1 staff, and the Manager was present. At this inspection the above noted contraventions were identified. Please correct the above noted contraventions by July 28, 2021. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy was sent to the Manager.

The following education/recommendations were provided:

-The reportable incident reporting procedure.
-The current COVID-19 protocols that are in place
-Active supervision

The inspection findings were reviewed with the Manager at the inspection. Due to the COVID-19 pandemic the inspection report and the risk assessment were completed at the Burnaby FHA office. The report was written in 1 hour and this is included in the report. A copy of these documents were sent to the Manager.
If you have any questions regarding this report please contact me.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Jul 28, 2021

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