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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SREL-AVCV4X

FACILITY NAME
Nurturing Hearts Montessori Daycare - Newlands
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 #
LSEO-ANYMRQ
FACILITY ADDRESS
21025 48th Ave
FACILITY PHONE
(604) 533-1805
CITY
Langley
POSTAL CODE
V3A 3M3
MANAGER
Colleen Patrick

INSPECTION DATE
January 25, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
01:00 PM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
81

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

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: 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 a storage room in the group child care school age program, which houses the hot water tank to be unlocked and containing hazardous substances, such as acid bowl cleaner. This was discussed with the staff on site.
Also observed a spray bottle containing a bleach and water solution was accessible on the bathroom counter to which a step is in place for children to wash their hands.
Corrective Action(s): Please ensure that children do not have access to hazardous materials.
Date to be Corrected: Jan 26th 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: On review of 6 staff files, Licensing observed 2 staff had RCMP checks in their file and not clearances form the Criminal Record Review Branch.
Corrective Action(s): Please ensure these staff have appropriate clearances on file.
Date to be Corrected: Feb 1st 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: On review of 6 staff files, Licensing observed that 1 staff was missing a current validation from the Registry.
Corrective Action(s): Please ensure any newer qualified staff has had their credentials validated.
Date to be Corrected: Feb 1st 2018

RECORDS AND REPORTING: 19030 - CCLR s.55(2)(a) - A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee.
Observation: On review of the minor incident log book in the school aged program, Licensing reviewed 2 entries which would have requiried a reportable incident to be submitted to Licensing. This was discussed with the training Manager on site.
Corrective Action(s): Please ensure all incidents referred to in Schedule H of the Child Care Licensing Regulations are reported to Licensing in a timely manner.
Date to be Corrected: N/A

RECORDS AND REPORTING: 19052 - CCLR s.56.1(2)(b) - A Licensee must keep (b) a current record of each person to whom the written agreement is delivered in accordance with that section [CCALA s.19]
Observation: On review of a random selection of 16 children's files, Licensing observed 3 that were missing a copy of the signed repayment agreement.
Corrective Action(s): Please ensure all children's files are complete at the time of enrolment.
Date to be Corrected: Feb 1st 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: On review of a random selction of 16 children's files, Licensing observed that 2 were missing Doctors information.
Corrective Action(s): Please ensure children's information is complete.
Date to be Corrected: Feb 1st 2018

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 care plans in the group child care 30 months to school age program and observed that children requiring medication did not have care plans in place which identified the signs and symptoms that the child/ren may present with and the relevant course of action to be taken by the staff to meet their needs. Licensing notes that complete medication consents were in place as required.
Corrective Action(s): Please ensure any child requiring any additional support has a care plan in place to effectively support their needs.
Date to be Corrected: Feb 1st 2018


Comments

Licensing was on site to conduct the 6th month routine inspection. Facility has been licensed since September 2017.
On site today was 11 staff. The Manager had just left for the day and 1 staff is transitioning as Manager within the next few weeks.
Staff to child ratio meets licensing regulations.

Licensing observed the staff interaction in the Group child care under 36 month programs and the Group child care 30 months to school age program.
Staff were able to meet children's needs and communication with appropriate language and guidance techniques.

Children were napping at the time of Licensing's arrival and gradual woke up to have free play activities. Those not napping were having quiet activities at tables.
Staff were knowledgeable with children's documentation as well as fire safety drills and facility procedures.

Discussed with staff:
Minor incident log book records - Licensing recommends ensuring a record is made of when the parents are informed of incidents. Staff inform parents verbally of any minor incidents when they occur.
Attendance records for the school age program need further clarification to ensure that children leaving the facility for school is clearly documented as no longer being present in the facility. This is especially important in an emergency situation.
Lighting in the facility at naptime can be a concern for some children that are not sleeping. Licensing observed children having table top activities with no light available. This is not conducive to their learning. Licensing recommends soliciting feedback from staff working in those areas who may be able to provide useful insight.
Fridge thermometer in one of the Infant rooms was a little over the required temperature for safety of perishables. Licensing recommends checking that thermometers are working correctly.
On review of staff files, Licensing observed checklists for character references. Licensing recommends making a note of comments made when checking references.
Licensing also recommends ensuring that qualified staff are located in the programs required.

Licensing notes that the Licensee file is not complete on site. Please ensure that all Licensee information is copied to the facility file.

No other concerns noted other than above.
The report was reviewed with the training Manager.
If you have any concerns regarding this report, please contact your Licensing Officer.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Feb 01, 2018

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