LICENSING: 10030 - CCLR s.10(2)(b) - Licensees must not make any structural change to a community care facility unless the licensee first (b) receives written approval from the medical health officer.
Observation: The Manager informed Licensing the perimeter fencing was replaced while the facility was closed during the months of April and May 2020. The City of Burnaby required the landlord to replace the fence and the Licensee was unaware of the changes until they reopened the facility.
Corrective Action(s): Ensure Licensing is informed of any structural changes as Licensing needs to approve the changes.
Date to be Corrected: 31 July 2020
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: Licensing noted the name of the facility Manager is not posted.
Corrective Action(s): Ensure the name of the Manager is posted for individuals to identify who is in charge.
Date to be Corrected: 31 August 2020
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: 1) on July 23, 2020 Licensing saw animal feces in the resilient surfacing of the fenced in play area. The Director of Licensing Safe Play Spaces require staff to conduct a daily check of the playground and maintain a record.
2) the landlord has replaced the perimeter fencing of the play area. The Licensee said the fence height was previously approximately 6' high and Licensing measured the new fence and it is approximately 3'6" high. The grade outside the fence is approximately 12' and a fence height should be, at a minimum 6' to mitigate risk for children. Licensing took 2 photographs of the fence and provided the Licensee with copies with this report.
Corrective Action(s): 1) Ensure staff conduct a daily safety check of the play space for garbage, broken glass, animal feces and other hazardous items and maintain a log of the inspections, maintenance and repairs.
2) The Licensee and Manager discussed the fence height with Licensing. The Licensee will need to address the issue of the fence height by August 31, 2020 and have Licensing approve of any changes. The facility will be closed for the month of August 2020 and in the meantime staff will need to practice active supervision until the end July 2020.
Date to be Corrected: 31 August 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11020 - CCLR s.13(2) - A licensee must ensure that the community care facility and the furniture, equipment and fixtures within it are clean and in good repair while children are in attendance.
Observation: Licensing observed rust in the following areas:
- boys washroom; a lower portion of a large painted pipe has areas of rust.
- outdoor swing set with 2 swings; the chains on both swings are completely rusted.
- main entry wooden gate; the latch is completely rusted and the hinges are showing signs of rust.
Rust is a potential health hazard.
Corrective Action(s): Repair or replace the above noted items to remove the rust.
Date to be Corrected: 31 August 2020
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: The kitchen area has doors and during both days the Licensing was inspecting the doors leading into the kitchen were left open. Licensing observed cleaning supplies including sanitizing products and staff purses accessible to children. The Manager and the Licensee both indicated that children know they are not permitted in the kitchen.
Corrective Action(s): All hazardous items must be kept out of reach of children to prevent a child from inadvertently being injured or poisoned. While staff supervision can be a portion of the plan to prevent children from accessing items there remains the potential for a child to access items without a staff being aware.
Date to be Corrected: 30 July 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11230 - CCLR s.47 - A licensee must ensure that any heated water accessible to children is heated to no more than 49° Celsius.
Observation: There is a water dispenser in the main activity room that dispenses both hot and cold water. The Licensee said the hot water is about the same temperature as boiling water as staff use the water for the hot beverages. There is a corrugated board placed across the dispenser however children still have easy access to the dispensers. There is the potential for a child to receive a burn or be scalded from the hot water. NOTE: this item has been previously coded on facility inspection report #KSEY-A2ENPM dated September 16, 2015.
Corrective Action(s): The Licensee is considering installing a panel/door with a lock to be placed in front of the machine.
Date to be Corrected: 30 July 2020
STAFFING: 12110 - CCLR s.19(2)(b) - A licensee must not employ a person in a community care facility unless the licensee is satisfied, based on the information available to the licensee under subsection (1) and the licensee's or, in the case of an employee who is not the manager, the manager's own observations on meeting the person, that the person (b) has the personality, ability and temperament necessary to manage or work with children.
Observation: Upon review of four staff files Licensing noted that all files were missing verification of the individual's references. NOTE: this item was previously contravened on facility inspection report #KSEY-AXXNC5 dated April 18, 2018.
Corrective Action(s): The Manager and/or Licensee will need to develop and implement a system to demonstrate that they have verified staff references.
Date to be Corrected: 31 August 2020
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 staff files and noted of the three files reviewed two files were missing evidence that the Manager and/or Licensee verified the individual's early childhood educator's certificate. NOTE: this item was previously coded on facility inspection report #KSEY-AZZNC5.
Corrective Action(s): Prior to individuals commencing work the Manager/Licensee must ensure that staff files are complete.
Date to be Corrected: 31 August 2020
PROGRAM: 18030 - CCLR s.44(1)(c) - A licensee must provide to children a comprehensive and coordinated program of indoor and outdoor activities that (c) complies with the program standards set out in Schedule G.
Observation: In the facility's outdoor play area there is a slide and a swing set with 2 swings. The Manager and Licensee said that staff bring out a bucket of toys for children to use outdoors. Upon review of the items in the bucket and in discussion with the Manager and Licensee they are not meeting the requirements for gross motor activities as per Schedule G.
In addition to the play area with the above noted fixed equipment there is another outdoor play area as per the facility's exemption for outdoor play area. The one play area is only sufficient for 10 children and the secondary play area must be made accessible to children when there are over 10 children in care. This area may be a place where staff can provide additional gross motor (large motor) activities.
Corrective Action(s): Licensing is requesting the Manager and/or Licensee submit a written action plan as to how staff will amend their outdoor activities to meet the legislative requirements. NOTE: children must have daily outdoor play for a minimum of 60 minutes per day.
Date to be Corrected: 31 August 2020
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