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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CLAN-BZFU7K

FACILITY NAME
Deer Lake Seventh-Day Adventist School
SERVICE TYPES
305 Group Child Care (School Age)
FACILITY LICENSE #
BHAN-BEUMA6
FACILITY ADDRESS
5550 Gilpin St
FACILITY PHONE
(604)
CITY
Burnaby
POSTAL CODE
V5G 2H6
MANAGER
Clea Bag-Ayan

INSPECTION DATE
March 19, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
03:30 PM
DEPARTURE
05:30 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 areas of the facility were inspected for compliance with the exception of the outdoor play area. In discussion with the Manager it was confirmed that the school board maintains the outdoor play area.

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: 11190 - CCLR s.16(4)(b) - A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.
Observation: Licensing observed a hanging bar that was located in the multi-purpose room. The hanging bar was approximately 5 feet 5 inches from the wooden floor. There was no resilient surface located underneath the hanging bar.
Corrective Action(s): Please ensure the equipment inside the facilty is free from hazards.
Date to be Corrected: March 26, 2021

MEDICATION: 16050 - CCLR s.53(3)(a) - A licensee must ensure that at all times an employee is available who is competent to either (a) administer a child's medication as instructed by the child's parent or required by the child's record or care plan.
Observation: During the inspection licensing reviewed the children's files. In a child's file it was noted that a care plan was completed and medication was required in the event of an emergency. In discussion with the Manager she was unaware of the directions in the child's care plan and where the child's emergency medication was located. It is concerning to licensing that the Manager may not be prepared to assist the child requiring medication in an emergency.
Corrective Action(s): Please ensure that staff are familiar with the details in a child's care plan and where emergency medication is located to be prepared in case it is required in an emergency.
Date to be Corrected: March 26, 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: During the inspection five children's records of sixteen were reviewed. Three children's records were missing a date of enrollment.
Corrective Action(s): Please ensure children's records are complete.
Date to be Corrected: April 9, 2021

RECORDS AND REPORTING: 19260 - CCLR s.58(2)(b) - The licensee must (b) 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.
Observation: Licensing reviewed a child's care plan. According to the date on the care plan this had not been reviewed annually.
Corrective Action(s): Please ensure a child's care plan is reviewed annually and the date the plan was reviewed is documented to ensure the information is current.
Date to be Corrected: April 9, 2021


Comments

At the inspection dated March 19, 2021 there were 16 children, 2 staff members and the Manager were present. At this inspection the above noted contraventions were identified. Please ensure the above noted contraventions are corrected by April 9, 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
Apr 09, 2021

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