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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-B57Q2T

FACILITY NAME
Beyond Care
SERVICE TYPES
302 Group Child Care (30 months to school age)
310 Multi-Age Child Care
FACILITY LICENSE #
3283113
FACILITY ADDRESS
8350 11th Ave
FACILITY PHONE
(604) 521-8748
CITY
Burnaby
POSTAL CODE
V3N 2P4
MANAGER
Khairunessa (Nessa) Karim Ahmed

INSPECTION DATE
October 03, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:30 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
9

Introduction

Licensing conducted an unscheduled routine inspection of this community care facility (CCF) to assess compliance w/ the:
• Community Care & Assisted Living Act (CCALA)
• Child Care Licensing Regulation (CCLR)
• Director of Licensing Standard of Practice (DLSP)
- Active Play
- Safe Play Space

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

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

As part of this inspection, Licensing completed & provided a risk assessment tool, which includes:
• any noncompliance identified
• the CCF's compliance & operational history since 03/Oct/2015

Contraventions
Previous Inspection - Contraventions observed on FIR #CGEE-AN3PMY 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
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: Employee:
- A lacked a copy of their CRC in the CCF
- B's CRC was addressed to their previous organization
Corrective Action(s): The manager stated that Employee:
- A's CRC was applied for a month ago upon hire
- B will apply for a CRC share as soon as possible
Date to be Corrected: 10/Oct/2018

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: An employee lacked a character reference.
Corrective Action(s): Please ensure that all requirements of s. 19 are obtained by employees' 1st day of employment.
Date to be Corrected: 10/Oct/2018

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: 2 employees lacked their immunization status.
Corrective Action(s): The licensee must ensure that all requirements of s. 19 are obtained by employees' 1st day of employement.
Date to be Corrected: 10/Oct/2018

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 (CORRECTED DURING INSPECTION): 2 employees' ECE or ECEA certificates haven't been validated.
Corrective Action(s): The licensee must ensure that employees' ECE or ECEA certificates are validated upon very renewal, as well as for all new hires.
Date to be Corrected:

STAFFING: 12470 - CCLR s.60(4) - Immediately after a person who was the subject of a character reference is no longer employed by or ordinarily present at the community care facility, a licensee must return all character references to the person, or destroy the character references.
Observation: Former employees' character references were still in their file.
Corrective Action(s): The licensee must ensure that character references are returned or destroyed after employees' last day of employment.
Date to be Corrected: 10/Oct/2018

POLICIES AND PROCEDURES: 13100 - 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.
Observation: This policy hasn't been developed & implemented yet.
Corrective Action(s): The licensee must develop & implement this policy.
Date to be Corrected: 31/Oct/2018

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 developed & implemented yet.
Corrective Action(s): The licensee should share this policy w/ parents/families.
Date to be Corrected: 31/Oct/2018

POLICIES AND PROCEDURES: 13120 - DLSOP Active Play - The Licensee must develop and implement a Screen Use Policy to guide employees in the use of screen time activities.
Observation: This policy hasn't been developed & implemented yet.
Corrective Action(s): The licensee must develop & implement this policy.
Date to be Corrected: 31/Oct/2018

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 developed & implemented yet.
Corrective Action(s): The licensee should share this policy w/ parents/families.
Date to be Corrected: 31/Oct/2018

RECORDS AND REPORTING: 19052 - CCLR s.56.1(2)(b) - A Licensee must keep (b) a current record of each person to whom the written agreement is delivered in accordance with that section [CCALA s.19]
Observation (CORRECTED DURING INSPECTION): There was no record of this requirement being met.
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 19070 - CCLR s.57(2)(a) - A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: - 2 children lacked their MSP #
- 1 child lacked his immunization status
Corrective Action(s): The licensee must ensure that all requirements of s. 57 are obtained by children's 1st day of care.
Date to be Corrected: 10/Oct/2018

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): 4 children's enrolment dates were missing.
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure.
Observation (CORRECTED DURING INSPECTION): - 3 children present during this inspection weren't signed in on the attendance
- 3 school-age children weren't signed out upon departure for school today
- there's no seperation on the attendance between the GCC (30 months - school age) children & the MACC children
Corrective Action(s): Accurate attendance records will assist 1st responders in the event of an emergency.
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: 2 children lacked their medical practitioner's name & phone #.
Corrective Action(s): The licensee must ensure that all requirements of s. 57 are obtained by children's 1st day of care.
Date to be Corrected: 10/Oct/2018

RECORDS AND REPORTING: 19370 - DLSOP Safe Play Space (maintenance of equipment [b3]) - [bullet 3] Keep a log of all inspections, maintenance and repairs.
Observation: The manager was unaware of this requirement.
Corrective Action(s): The licensee must ensure that all inspections (daily/monthly/annual), maintenance, & repairs to the outdoor play space are documented.
Date to be Corrected: 10/Oct/2018


Comments

The CCALA, CCLR, & DLSP set the minimum standards that must be met by all licensed CCFs to ensure the health & safety of all vulnerable individuals in care. The onus rests w/ the licensee to provide for the health & safety of all children in care @ all times.

Continuous, active supervision (s. 39 of the CCLR)
Licensing discussed how the licensee must ensure that:
• children are actively supervised @ all times by ≥ 1 responsible adult while maintaining the minimum employee to children ratio @ all times
• employees practice active supervision via a combination of close proximity & attention, watching, & listening, while being able to move through & see the entire space that children are in

Notification of illness or injury (s. 55 of the CCLR)
Licensing discussed how the licensee must notify:
• a parent or emergency contact immediately after the child becomes ill, injured, or is (possibly) involved in a reportable incident (RI) while in care
• Licensing within 24 hrs after a child is (possibly) involved in an RI while in care
- this requirement can be fulfilled via email, phone, or fax
- in Licensing's absence, please report to FHA's Population & Public Health Central Call Centre (604.587.3936)
- please deliver the yellow copy of the completed RI form to the Bby Health Protection office (#300 - 4946 Canada Way, Bby, BC V5G 4H7)

Safe drinking water (s. 48 of the CCLR)
Recent testing in many communities has shown higher concentrations in tap water than previously expected. Licensing discussed the importance of flushing pipes by running the cold water tap, as per the provided BC Govt Fact Sheet (CCLR, CCALA): "Lead in Drinking Water."

Licensing:
• reviewed this FIR w/ the manager prior to signing & printing
• thanks the manager for her time & assistance today

Please visit http://www.fraserhealth.ca/childcare/ for:
• links to the CCALA, CCFL,& DLSP
• PHSA's free online course (Healthy Eating in the
Child Care Setting - Division of Responsibility model) • 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 10, 2018

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