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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SWAR-BX6U25

FACILITY NAME
Bright Angels Children's Centre II
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
SRID-7EUMMT
FACILITY ADDRESS
21176 Yeomans Cres
FACILITY PHONE
(604) 888-8786
CITY
Langley
POSTAL CODE
V1M 2P7
MANAGER
Chandani Liya Wijesinghe

INSPECTION DATE
January 11, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.25
ARRIVAL
10:05 AM
DEPARTURE
11:55 AM
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 reviewed for compliance.
A risk screening was conducted prior to the inspection

Contraventions
Previous Inspection -
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: Licensing observed the following:
- Carpet area in the School age program has dirty spots all over it.
- Sleeping mats in the 3-5 program are torn, have holes in and are accessible to children
- Staff purses are stored in a lower area accessible to children
Manager said that the carpet is going to be cleaned over a weekend and will replace the sleeping mats. Discussed the appropriate location of staff purses.
Corrective Action(s): Please ensure a safe and healthy environment for children at all times. Please provide a corrective action plan by the date below.
Date to be Corrected: January 25th 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11160 - CCLR s.16(3)(a) - A licensee must ensure that the entire outdoor play area is (a) enclosed in a manner that is suitable for the age and development of children, and will ensure that children are free of harm.
Observation: Licensing observed the GCC (30-sa) play are fence has various areas where the fence panels are broken/splintered or rotten and cause concern for injury. Manager stated that there is a plan in place to have the fence replaced with new.
Corrective Action(s): Please provide a corrective action plan by the date below as to when the fence will be replaced to ensure children are free from harm.
Date to be Corrected: January 25th 2021

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: On review of three staff files, Licensing observed that two staff had expired criminal record checks. Licensing does acknowledge that the facility have started the process of renewal but have yet to complete the process with receipt of the clearance.
Corrective Action(s): Please ensure that this process is completed immediately - these staff do not work alone.
Date to be Corrected: January 13th 2021

STAFFING: 12070 - CCLR s.19(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Licensing observed that all staff in the GCC (30-sa) program had expired first aid certificates. Due to the pandemic this was exempted for 6 months and one staff is now signed up for a course on January 16th 2021, with the others on waitlists. There are other staff members on site with current first aid training.
Corrective Action(s): Please submit a compliance plan as to when the other staff will have been re-certified.
Date to be Corrected: January 25th 2021

STAFFING: 12090 - CCLR s.19(1)(f) - 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: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Licensing reviewed three staff files of which two were missing immunization status
Corrective Action(s): Please ensure staff files are complete prior to employment
Date to be Corrected: January 25th 2021

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: Licensing reviewed three staff files and noted one staff was missing a current certificate validation.
Corrective Action(s): Please ensure updated certificates are valid upon receipt.
Date to be Corrected: January 25th 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: Licensing observed that the annual emergency drill had not been completed. Manager said that due to Covid, the restrictions for access at their secondary location prevented the drill. Discussed the requirements for the drill, not just the location
Corrective Action(s): Please ensure an annual emergency evacuation drill is conducted with all staff.
Date to be Corrected: January 25th 2021

POLICIES AND PROCEDURES: 13080 - CCALA s.19 - If a person prepays part of the cost of services provided by a class of community care facilities designated by the Lieutenant Governor in Council, the licensee must, at the time of the prepayment, deliver to the person a written statement setting out the terms and conditions on which a refund of all or any of the prepayment will be made.
Observation: On review of twelve children's files, three were missing prepayment contracts. Discussed further with the Manager and provided some recommendations.
Corrective Action(s): Please ensure you have a record of each family receiving the prepayment details.
Date to be Corrected: January 25th 2021

RECORDS AND REPORTING: 19220 - CCLR s.58(1)(b) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (b) the courses of action recommended by health care professionals to address the needs of the child requiring extra support.
Observation: Licensing reviewed information provided to support two children requiring emergency medication which did not include the signs and symptoms for staff to look out for. This is necessary information to help guide staff to appropriately respond with a course of action. The medication was also expired. Licensing acknowledges that medication forms were available for each medication required.
Corrective Action(s): Please ensure any child requiring extra support has a current care plan in place and medication is safe to administer.
Date to be Corrected: January 25th 2021


Comments

Summary of Inspection
At today’s inspection there were 20 children in the Group Child Care (30 months to school age) program with 3 staff and 9 children and 3 staff present in the Group Child Care (under 36 month) program. The Manager also arrived on site to assist Licensing.

At this inspection the above noted contraventions were identified.
Licensee is required to submit a corrective action plan to address the contravention/s
Licensing will review the corrective action plan
As part of this Routine Inspection a Facility Risk Assessment Tool was completed and a copy was provided along with the report.

The following education/recommendations were provided through discussion:
- Requirement of annual emergency evacuation drill
- Updating of facility policies to assist with prepayment contracts
- Outdoor renovation plans
- Fridge thermometer in the infant/toddler fridge and using bleach and water to clean small spots of mold in the windows.

Visit the CCFL website at www.fraserhealth.ca/childcare
for additional resources, and links to the Legislation (CCALA and CCLR).

Further websites:
Criminal Records Checks at:
www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
Appetite to Play at: https://www.appetitetoplay.com
Healthlink BC at: https://www.healthlinkbc.ca/services-and-resources/healthlinkbc-files


This inspection report was reviewed with the Licensee/Manager prior to be written off-site and was emailed once completed.
If you have any concerns or further questions regarding the content of this report, please contact your Licensing Officer. (Contact details provided)

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Due Date
Jan 25, 2021
Approximate Follow Up Date
26 Feb, 2021

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