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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KINE-CWRVQY

FACILITY NAME
CEFA South Delta
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
MLAO-AN5PJN
FACILITY ADDRESS
202 - 4890 Canoe Pass Way
FACILITY PHONE
(604) 382-4274
CITY
Tsawwassen
POSTAL CODE
V4M 0B1
MANAGER
Yat Lok Nian Chan

INSPECTION DATE
October 19, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
11:45 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care Assisted Living Act (CCALA) and 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
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: The walls in three out of six classrooms have chipped paint and areas where the drywall is exposed at the child level. (this is a repeat contravention)
Corrective Action(s): Repair all classroom walls where paint is chipped and drywall is exposed
Date to be Corrected: November 2, 2023

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: 1. Two of the children's nap rooms have electrical outlets at the childrens level with video surveillance equipment plugged into them.The equipment is located directly next to the sleeping cot and can be reached by the child who may be sleeping nearby. (this is a repeat contravention)
2. Sanitization wipes were stored on the counter of the washroom and were accessible to children in care (corrected during inspection)
Corrective Action(s): 1. All outlets must be secured so that children do not have access
2. Sanitization wipes must be stored out of reach from children as directed on the product label.
Date to be Corrected: November 2, 2023

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: Seven staff files were reviewed and one staff was found to have an expired Criminal Record Check. During the inspection, the licensee initiated the process of obtaining an updated criminal record check for this staff.
Corrective Action(s): Ensure all staff have current Criminal Record Checks in place
Date to be Corrected: November 2, 2023

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: All classrooms had practiced fire drills and records kept but none of the classrooms had a record of Emergency drills.
Corrective Action(s): Ensure that Emergency drill is recorded and practiced once per year
Date to be Corrected: November 2, 2023


Comments

At today’s inspection there were 67 children and 17 staff present. Licensing conducted a walk through of the entire facility.
At this inspection the above noted contraventions were identified. The Licensee will take action to bring the facility into compliance and provide a written response to the Licensing Officer byNovember 2, 2023. The Licensing Officer will review the response.
As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy was provided to the facility along with this report. The Risk Assessment includes any non-compliance identified during the routine inspection and a 3 year ‘historical’ review of the facility’s compliance and operation and is used to determine inspection frequency.
The contents of the inspection report were reviewed with the licensee prior to the inspection report being written off-site; therefore, no signature attached. A copy of this report will be emailed to the manager on October 19, 2023.
The Licensing Officer met with the manager and discussed the following:
Care Plans
Relocation of unit that dispenses hot water on demand from hallway to staff room
First aid supplies
Verification of references

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
Nov 02, 2023

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