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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
ABEY-B4TTQW

FACILITY NAME
1st Step Montessori Inc - Sunbury Hall
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
MLAO-A92NPK
FACILITY ADDRESS
10409 Dunlop Rd
FACILITY PHONE
(604) 417-3290
CITY
Delta
POSTAL CODE
V4C 2L1
MANAGER
Randeep Bal

INSPECTION DATE
September 21, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
02:35 AM
DEPARTURE
05:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
30

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DLP). Evidence for this report was based on the licensing Officers 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 & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Programming, Records and Reporting
As part of the Routine Inspection a Facility Risk Assessment is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at https://www.fraserhealth.ca/health-info/health-topics/child-care/ for additional resources and links to the legislation (CCALA & CCLR).

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: 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: One staff who works with children does not have her certificate posted.
Corrective Action(s): Ensure all certificates for all staff are posted.
Date to be Corrected: 24-Sep-2018

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 blind cords hanging low in access to children. Another cord was observed in the nap room (strangulation hazard). Staff staff stated that a disinfection step is not done in the upstairs program to mitigate the risk of spreading germs.
Corrective Action(s): Ensure a healthy and safe environment is provided at all times.
Date to be Corrected: 24-Sep-2018

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 (CORRECTED DURING INSPECTION): Licensing observed cupboards in the kitchen that had child locks on them, however these locks were not secured leaving the cupboards unlocked. Inside one of these cupboards is cleaning supplies including bleach. licensing observed children freely access this area. There is a gate, however this did not keep children out of this area. Licensing observed that this cupboard was locked by the end of this inspection.
Corrective Action(s): Ensure that children do not have access to hazardous substances.
Date to be Corrected:

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: There is one staff file with Criminal Record Checks from a third party and another staff file without a Criminal Record Check in place in the file. This is a Repeat Conravention.
Corrective Action(s): Ensure Criminal Record Checks are obtained prior to employees working with children. The manager ensured that these staff will not work alone with children until a CRC is in place from the CRC review program.
Date to be Corrected: ASAP

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 review of 4 staff files showed that 1 of these does not have evidence of references.
Corrective Action(s): Ensure references are checked for all employees prior to working with children.
Date to be Corrected: 28-Sep-2018

STAFFING: 12280 - CCLR s.34(4)(a) - Despite this section, during the half hour before a care program begins and the half hour after a care program ends, a licensee may permit children who would otherwise be grouped in different care programs, and who are arriving at or leaving the community care facility, to be grouped together and supervised other than as required under Schedule E if (a) the care program is described as Multi-Age Child Care, Group Child Care (Under 36 Months), Group Child Care (30 Months to School Age) or Group Child Care (School Age).
Observation: Staff stated that the programs overlap for one hour at the beginning and ending of each day.
Corrective Action(s): Ensure the program overlap for only the allowable 30 minutes at the beginning and ending of each day.
Date to be Corrected: 24-Sep-2018

STAFFING: 12290 - CCLR s.34(4)(b) - Despite this section, during the half hour before a care program begins and the half hour after a care program ends, a licensee may permit children who would otherwise be grouped in different care programs, and who are arriving at or leaving the community care facility, to be grouped together and supervised other than as required under Schedule E if (b) a total of 8 or fewer children are present at the community care facility, of whom no more than 3 are younger than 36 months old.
Observation: LIcensing observed that there were 4 children under the age of 3 in care while the programs were overlapping in the morning on this day (more than the allowable 3).
Corrective Action(s): Ensure that no more than 3 children under 36 months are in care when the programs overlap.
Date to be Corrected: 24-Sep-2018

CARE AND/OR SUPERVISION: 14010 - CCLR s.34(1) - A licensee must ensure that children are adequately supervised by qualified employees in sufficient numbers to meet the needs of each child.
Observation: Staff described a staff schedule that does not have the required staffing in place - IT staff is not in place more than 2 hours each day.
Corrective Action(s): Ensure qualified staff is in place.
Date to be Corrected: 28-Sep-2018

CARE AND/OR SUPERVISION: 14020 - CCLR s.34(2)(a) - Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.
Observation: licensing observed that the IT and GCC 30 months to SA program have switched rooms. The current license allows for 8 children between 30 months and school age, however there are regularly more than this in attendance.
Corrective Action(s): Ensure that each group is limited to the number of children that the license allows.
Date to be Corrected: 28-Sep-2018

MEDICATION: 16020 - CCLR s.53(1)(b) - If a licensee has agreed with a parent to give a child any medication prescribed by a medical practitioner or provided by the parent, the licensee and his or her employees must ensure that the medication is (b) readily accessible to employees.
Observation: A child is in care who requires emergency medication, however this medication was not available while the child was in care during this inspection.
Corrective Action(s): Ensure required medication is in place as required.
Date to be Corrected: prior to this child attending

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: There is a child in care who requires extra support, however staff stated that there is no care plan in place.
Corrective Action(s): Ensure care plans are in place as required to direct staff in how to respond to children's needs.
Date to be Corrected: Prior to this child being in care.


Comments

Discussions were had around:
· Active Supervision – this includes scanning and counting, setting up the environment, anticipating children’s behaviours and abilities, positioning yourself and listening.
o Supervision policies: Transportation policy / bathroom supervision / after school pick up / drop off . Supervision practices were observed.
· Flushing taps to reduce lead (older facilities). One way to reduce lead in drinking water is to flush all water taps used for drinking water or food preparation at the start of each day or after periods of stagnation. More information can be found at https://www.fraserhealth.ca/health-info/health-topics/drinking-water/. This facility provides filtered water.
· Serious Incident reporting - contact Licensing. Ensure you have notified Licensing within 24 hours. If you cannot reach your Licensing Officer, please contact the Duty Line at 604-587-3936.
The staff were seen to have respectful interactions with the children, including responding to their needs immediately, smiling at them, getting down to their level, using positive guidance and providing choices. The children were seen to participate in active circle times, play outside, receive soothing from caregivers after nap time, play with play doh and engage socially with each other. The caregivers demonstrated skill and competency in guiding and caring for children.
Thank you for your assistance with this inspection.
materials provided: Check list, Is your Child Safe - Sleep Time, Live 5210 resource.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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