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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

MZIN-D28VUZ

FACILITY NAME Douglas Road Neighbourhood Care		SERVICE TYPES 306 School Age Care on School Grounds	FACILITY LICENSE # GLAE-63HT5P
FACILITY ADDRESS 4861 Canada Way			FACILITY PHONE (604) 298-7094
CITY Burnaby	POSTAL CODE V5G 1L7		MANAGER Jacllyn DiVito

INSPECTION DATE February 06, 2024	ADDITIONAL INSP. DATE (multi-day) February 07, 2024		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2
ARRIVAL 03:05 PM	DEPARTURE 04:20 PM	ARRIVAL 03:40 PM	DEPARTURE 04:25 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 11

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.

Contraventions

Previous Inspection -

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

Observed Violations

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 all staff files are complete. Date to be Corrected: Feb. 14, 2024 POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must: (b) have 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 required service and had a date of Aug. 09, 2023 on the tag. Corrective Action(s): The manager said that she has spoken to the school and the fire extinguisher will be serviced as soon as possible. Date to be Corrected: Feb. 09, 2024 POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment]. Observation (CORRECTED DURING INSPECTION): Licensing observed that for the month of January 2024, the date which the fire and emergency drill was completed was not documented. The manager said that both drills were completed with the children, and was just not recorded by staff. This is a repeat contravention and was noted on Jan. 03, 2023 on report number MZIN-CMQW4Q. Corrective Action(s): The manager has written the date of the drills and noted when they were completed on the log sheet, for the month of Januray 2024. Date to be Corrected: 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: Licensing observed that two children did not have the name and phone number of their medical practitioner/clinic on file. Corrective Action(s): The manager said that she has began to connect with the parents to ensure this information is on file. Date to be Corrected: Feb. 14, 2024 RECORDS AND REPORTING: 19160 - CCLR s.57(2)(i) - A licensee must keep, for each child, a record showing the following information: (i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency. Observation: Licensing observed that there were three children who did not have a photo/digital image on file. Corrective Action(s): The manager said that she has started to gather the photos/digital image of the children for the files, and will inform Licensing once it has been completed. Date to be Corrected: Feb. 14, 2024

Comments

At the inspection dated Feb. 06, 2024 there were 11 children ,1 staff and 2 volunteers present.The manager was also on-site for both inspection dates and assisted Licensing. At this inspection, the above noted contraventions were identified. Actions required by the licensee includes a written response. The contraventions noted in this report were reviewed with the facility manager during the inspection. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided. The following recommendations/discussions were provided: - Reportable Incident procedures, which is to be reported within 24 hours. Child care staff are asked to call their Licensing Officer to make the report. If the Licensing Officer is unavailable, please call the Duty Line Licensing Officer. - Continue to document minor incidents using the incident log bound book, and take note of any illness and unexpected events involving children not requiring medical attention, and that are not reportable incidents as described in Schedule H and staff to continue to initial and write the date after each documentation. - Continue to constantly review facility policies - Continue to clean and sanitize the facility including toys and equipment - Check the expiry date of items in the emergency supplies kit - Remove all items with an NPN/DIN # in the first aid kit, as parent’s permission is required before using these items on children. Mild soap and water can be used to clean any minor cuts or scrapes. - Care plans and procedures - Procedure for organizing and updating staff files - Emergency bag and procedures The following resources were provided: - Care and Supervision: Care Plans - Your Checklist Child Care Links A copy of this report was sent to the facility. Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).

Action Required by Licensee/Manager	Action Required by Licensing Staff
Provide a written response to Licensing	No action required
Due Date Feb 14, 2024

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