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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
LPEN-CJJR9J

FACILITY NAME
Willowbrae Academy Langley
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
NKAR-C24TKC
FACILITY ADDRESS
100 - 8063 199th St
FACILITY PHONE
(778) 705-9264
CITY
Langley
POSTAL CODE
V2Y 0E2
MANAGER
Sukhraj Sandhu

INSPECTION DATE
September 23, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
08:15 AM
DEPARTURE
11:15 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 (DoLSoP). All care categories were inspected for compliance.

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

Observed Violations
LICENSING: 10050 - CCLR s.11(1) - A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation: The name of the Manager was not posted.
Corrective Action(s): Ensure the name of the Manager is posted.
Date to be Corrected: 25-Sep-2022

LICENSING: 10070 - CCLR s.11(4) - A licensee must display in a prominent place in the community care facility the certificate, or a copy of the certificate, of any educator or assistant employed to work in the community care facility.
Observation: 6 employee certificates were not displayed in a prominent place in the community care facility.
Corrective Action(s): Ensure that all certificates are posted in a prominent place in the community care facility.
Date to be Corrected: 3-Oct-2022

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:
-the laundry room door open with laundry detergent accessible.
-the door from the kitchen leading to the playground was open and the kitchen was left unoccupied and accessible to children
-paint is peeling in all classrooms exposing drywall
-blind cords were accessible to children in care
-many bathrooms did not have a covered garbage can
Corrective Action(s): Ensure that a healthy and safe environment is provided at all times
Date to be Corrected: 3-Oct-2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11090 - CCLR s.15(1)(b) - A licensee must supply equipment, furniture and supplies that are (b) located so as not to block or hamper an exit in the case of fire or other emergency.
Observation: The gate to the emergency exit is unable to be opened by a staff and the Licensing Officer.
Corrective Action(s): Ensure that the emergency exit is accessible in case of fire or other emergency.
Date to be Corrected: 23-Sep-2022

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: 5 employees did not have a copy of the criminal record check
Corrective Action(s): Ensure that each employee has a criminal record check.
Date to be Corrected: 26-Sep-2022

STAFFING: 12050 - CCLR s.19(1)(b) - 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: (b) character references in respect of the person.
Observation: 3 employee files did not contain character references
Corrective Action(s): Ensure that for each employee character references have been obtained.
Date to be Corrected: 30-Sep-2022

STAFFING: 12060 - CCLR s.19(1)(c) - 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: (c) a record of the person's work history.
Observation: 5 employees did not have a record of the person's work history
Corrective Action(s): Ensure that each person has a record of work history
Date to be Corrected: 30-Sep-2022

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: Immunization status was not obtained for four employees.
Corrective Action(s): Ensure that a record of immunization is obtained for all employees.
Date to be Corrected: 3-Oct-2022

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 system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: 5 employee certificates have not been verified
Corrective Action(s): Ensure that each educator or assistant certificate is verified by the system maintained by the early childhood educator registry.
Date to be Corrected: 30-Sep-2022

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: The staff was unable to show Licensing the daily attendance for children with the time of arrival or departure.
Corrective Action(s): Ensure that for each child there is a record of time of arrival and departure.
Date to be Corrected: 30-Sep-2022

RECORDS AND REPORTING: 19250 - CCLR s.58(2)(a) - The licensee must (a) develop the care plan in consultation with a parent of the child requiring extra support and any person requested by the parent.
Observation: 7 children requiring a care plan did not have one created.
Corrective Action(s): Ensure that each child requiring a care plan has one created
Date to be Corrected: 30-Sep-2022


Comments

Summary of Inspection
At the inspection dated September 23, 2022 there were 68 children and 23 staff present. At this inspection the above noted contraventions were identified. The Manager will take action to bring the facility into compliance and provide a written response to the Licensing Officer. The Licensing Officer will review the response. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.
The following education/recommendations were provided:
· Active Supervision
· Transitions of children between rooms and programs
· Outdoor Play schedule
· Lead in the Water

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

This report was written off site and emailed to the facility.

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
Oct 03, 2022

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