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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-ASAPW5

FACILITY NAME
St. Alban's The Martyr Day Care
SERVICE TYPES
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
3274013
FACILITY ADDRESS
7717 19th Ave
FACILITY PHONE
(604) 522-6228
CITY
Burnaby
POSTAL CODE
V3N 1E8
MANAGER
Pam Venketaya

INSPECTION DATE
October 19, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:15 AM
DEPARTURE
12:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
22

Introduction

An unscheduled routine inspection of this community care facility (CCF) was conducted by the licensing officer (FHA) to assess compliance w/ the:
• Community Care & Assisted Living Act (CCALA)
• Child Care Licensing Regulation (CCLR)
• Director of Licensing Standards of Practice (DLSP)

At the time of inspection, evidence for this facility inspection report (FIR) was based upon:
• FHA's observations
• FHA's review of the CCF's records
• information provided to FHA by employees

FHA reviewed these 10 areas today:
• licensing • hygiene & communicable disease control
• physical facility • medication
• staffing • nutrition & food services
• policies & procedures • program
• care & supervision • records & reporting

As part of this inspection, FHA completed & provided a risk assessment tool, which includes:
• any noncompliance identified • the CCF's compliance & operational history since 19/Oct/2014

Contraventions
Previous Inspection - Contraventions observed on FIR #CGEE-AHAQFA have been corrected except for those noted on supplementary pages.
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 (CORRECTED DURING INSPECTION): 2 employees' ECE or ECE(A) certificates (or copies of) weren't posted conspicuously.
Corrective Action(s):
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: FHA reviewed all employees' files & found that 2 employees lacked their CRC onsite. The manager stated that the CRCs arrived quite awhile ago, but she was unable to locate them in FHA's presence.
Corrective Action(s): Please ensure that all requirements of §19 are obtained by employees' 1st day of employment.
Date to be Corrected: 02/Nov/2017

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: FHA reviewed all employees' files & found that 1 employee lacked 3 references.
Corrective Action(s): Please ensure that all requirements of §19 are obtained by employees' 1st day of employment.
Date to be Corrected: 26/Oct/2017

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: FHA reviewed all employees' files & found that 1 employee lacked a copy of her work history.
Corrective Action(s): Please ensure that all requirements of §19 are obtained by employees' 1st day of employment.
Date to be Corrected: 26/Oct/2017

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: FHA reviewed all employees' files & found that 1 employee lacked her immunization status.
Corrective Action(s): Please ensure that all requirements of §19 are obtained by employees' 1st day of employment.
Date to be Corrected: 26/Oct/2017

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: The manager has validated (& documented the results of) 3/6 employees' ECE or ECE(A) certificates on the ECE Registry certificate validation website.
Corrective Action(s): Please validate the other 3 employees' certificates & print the results page or document that validation has been completed.
Date to be Corrected: 26/Oct/2017

POLICIES AND PROCEDURES: 13110 - DLSOP Active Play - [The Licensee must develop and implement an Active Play Policy to engage children in daily active play, consisting of un-facilitated play and facilitated games and activities.] This policy should also be shared with parents/families.
Observation: This policy hasn't been shared w/ parents/families yet.
Corrective Action(s): Please share this policy w/ parents/families.
Date to be Corrected: 01/Nov/2017

POLICIES AND PROCEDURES: 13130 - DLSOP Active Play - [The Licensee must develop and implement a Screen Use Policy to guide employees in the use of screen time activities.] This policy should also be shared with parents/families.
Observation: This policy hasn't been shared w/ parents/families yet.
Corrective Action(s): Please share this policy w/ parents/families.
Date to be Corrected: 01/Nov/2017

RECORDS AND REPORTING: 19080 - CCLR s.57(2)(b) - A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Observation (CORRECTED DURING INSPECTION): FHA reviewed 11 children's files & found that 1 child lacked his enrolment date.
Corrective Action(s):
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: FHA reviewed 11 children's files & found that 2 children lacked a medical practitioner's name & #.
Corrective Action(s): Please ensure that all requirements of §57 are obtained by children's 1st day of care.
Date to be Corrected: 26/Oct/2017

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: A child requiring extra support lacked a care plan.
Corrective Action(s): Please ensure that children who require support have a care plan in place.
Date to be Corrected: 24/Oct/2017

RECORDS AND REPORTING: 19370 - DLSOP Safe Play Space (maintenance of equipment [b3]) - [bullet 3] Keep a log of all inspections, maintenance and repairs.
Observation: Monthly inspections aren't documented.
Corrective Action(s): In addition to documenting maintenance, repairs, & daily inspections pertaining to the outdoor play space, please also document monthly & annual inspections.
Date to be Corrected: 31/Oct/2017


Comments

FHA:
• reviewed this FIR w/ the manager prior to signing & printing
• thanks all employees for their time & assistance today

Please visit http://www.fraserhealth.ca/childcare/ for:
• links to the CCALA, CCFL,& DLSP
• the temporary placement/retention application form • the exemption application form
• additional resources

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
Oct 26, 2017

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