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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKIM-C9CTSU

FACILITY NAME
Peregrine House School
SERVICE TYPES
302 Group Child Care (30 months to school age)
305 Group Child Care (School Age)
301 Group Child Care (under 36 months)
FACILITY LICENSE #
DMIL-A6CT9D
FACILITY ADDRESS
20381 66th Ave
FACILITY PHONE
(604) 357-4755
CITY
Langley
POSTAL CODE
V2Y 1P3
MANAGER
Nadin Elkhalil

INSPECTION DATE
December 03, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
08:45 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
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: Criminal Record Check not obtained for 3 staff members.
Corrective Action(s): Please ensure that all staff files are complete.
Date to be Corrected: Dec 13, 2021

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: A minimum of two character references were not obtained for 3 staff members.
Corrective Action(s): Please ensure that all staff files are complete.
Date to be Corrected: Dec 13, 2021

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: A record of the person's work history was not obtained for 3 staff members.
Corrective Action(s): Please ensure that all staff files are complete.
Date to be Corrected: Dec 13, 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: Immunization status was not obtained for 5 staff members.
Corrective Action(s): Please ensure that all staff files are complete.
Date to be Corrected: Dec 13, 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 system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: Validation from the registry was not obtained for 4 staff member's certificates.
Corrective Action(s): Please ensure that all staff files are complete.
Date to be Corrected: Dec 13, 2021

STAFFING: 12151 - CCLR s.19(5)(a) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (a) a criminal record check for the person.
Observation: A criminal record check was not obtained for one volunteer.
Corrective Action(s): Please ensure that CRC is obtained for the volunteer.
Date to be Corrected: Dec 13, 2021

STAFFING: 12152 - CCLR s.19(5)(b) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (b) character references in respect of the person.
Observation: A minimum of two character references were not obtained for one volunteer.
Corrective Action(s): Please ensure that minimum of 2 references are obtained for the volunteer.
Date to be Corrected: Dec 13, 2021

STAFFING: 12153 - CCLR s.19(5)(c) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Immunization status was not obtained for one volunteer.
Corrective Action(s): Please ensure that volunteer's immunizations status record is obtained.
Date to be Corrected: Dec 13, 2021

STAFFING: 12190 - CCLR s.22(2)(b) - A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.
Observation: Fire drill was not practiced with IT program for Nov. 2021
Corrective Action(s): Ensure that fire drill is completed with all children and staff monthly.
Date to be Corrected: Dec 16, 2021

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: Fire Extinguishers have not been serviced annually.
Corrective Action(s): Please ensure that all fire extinguishers are serviced annually.
Date to be Corrected: Dec 16, 2021

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: Monthly drills were not recorded for Oct and Nov 2021.
Corrective Action(s): Please ensure that records respecting compliance with monthly fire drills are up to date.
Date to be Corrected: Dec 16, 2021

CARE AND/OR SUPERVISION: 14030 - CCLR s.34(2)(b) - Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Observation: Infant/Toddler Ratio - Staff to Child ratio not maintained. (IT/ECE/ASST)
Corrective Action(s): Please ensure that ratio of staff to chidlren is maintained as per Schedule E of the CCLR.
Date to be Corrected: Dec 6, 2021


Comments

On the inspection date of December 3, 2021 there were 23 children and 7 staff present. At this inspection the above noted contraventions were identified and the Licensee is required to take corrective action to bring the facility into compliance and submit a written response by below date for Licensing to review. The contravention noted in this report was reviewed with the Manager during inspection. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is attached.
The following were discussed with the Manager:

- Unvaccinated traveller ( children under 12 years of age); see below link
COVID-19 vaccinated travellers entering Canada - Travel restrictions in Canada – Travel.gc.ca
- Manager's info and facility licence to be posted in a prominent place within the both portables
- Care plans for children requiring extra support
- Updated digital images/photos of children

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

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
Dec 17, 2021

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