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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KSEY-BHFQ9L

FACILITY NAME
Reach for the Stars Montessori
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
ACAK-8EUNVL
FACILITY ADDRESS
3440 Boundary Rd
FACILITY PHONE
(604) 688-7827
CITY
Burnaby
POSTAL CODE
V5M 4A5
MANAGER
Nidhi Kochar

INSPECTION DATE
October 30, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:45 AM
DEPARTURE
01:15 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 and Assisted Living Act (CCALA), the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSP). All areas of the facility were reviewed for compliance.

Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
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: During inspection Licensing was not able to view the facility Licence as it was located in a locked office.
Licensing also noted that the manager's name was also not prominently displayed.
Corrective Action(s): Ensure the facility licence and manager name are prominently displayed where parents can easily view them.
Date to be Corrected: Nov. 8/19

LICENSING: 10060 - CCLR s.11(3) - When advertising or otherwise offering services to the public, a licensee must identify the care program being offered.
Observation: During inspection Licensing observed the word "Preschool" on signs leading into the Group Child Care (30 month to school age) room.

As per section 4(a)(ii) A person who does not hold a licence must not do any of the following in relation to a program for children:
(a) use any of the following phrases in any part of the title or advertising of the program:
(ii) Preschool"

The Licensee can use other phrases to describe the part time program being offered in the Group Child Care (30 month to school age) program but not the term "preschool"

Corrective Action(s): Licensee to remove the term "preschool" from their signage and advertising
Date to be Corrected: Nov. 28/19

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: During inspection Licensing was not able to view the posted ECE Certificates for staff as they were locked in an office.
Corrective Action(s): Ensure ECE Certificates are prominently displayed for all staff in areas easily viewed by parents.
Date to be Corrected: Nov. 28/19

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: During inspection Licensing observed areas with paint missing and holes in the walls in all the naprooms for both programs.
Corrective Action(s): Licensee to repair the walls in the naprooms to remove children's access to the drywall.
Date to be Corrected: Nov. 28/19

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11190 - CCLR s.16(4)(b) - A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.
Observation: During inspection Licensing noted that the bark mulch has been displaced under some of the equipment such as: slide, ride on spring toy, which impacts the depth of the resilient surfacing in the fall zones.

Staff to inspect the outdoor play area daily and rake the bark mulch to ensure the depth of the resilient surfacing meets the requirements for the height of the equipment to mitigate the risk of injury due to falls.
Corrective Action(s): Staff to regularly inspect outdoor play area to ensure depth of resilient surfacing meets requirements.
Date to be Corrected: Nov. 8/19

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: During inspection Licensing observed the following:
- staff purses located on the floor in the 3-5 room
- suncreen, bottle of glue, soap located under the sink in the 3-5 washroom
- pest control boxes located under a cupboard in the 3-5 washroom

The above-noted items were corrected during inspection.

The following items still need to be addressed:

- plastic bags and soap located under the kitchen sink in the 3-5 room
- plug covers were missing in some outlets in all of the naprooms.
- basket being stored on top of a cupboard in the < 36 month naproom.
Corrective Action(s): Ensure all hazardous materials are made inaccessible to children.
Date to be Corrected: Oct. 31/19

HYGIENE AND COMMUNICABLE DISEASE: 15030 - CCLR s.46(1) - A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
Observation (CORRECTED DURING INSPECTION): During inspection Licensing noted that one towel was hanging in a toddler washroom area.
Staff stated that children used the towel to dry their hands with

Licensing discussed using individual towels or paper towels for children to dry their hands with to prevent the spread of germs.

This violation had been previously noted on inspection report #KSEY-B7DQ3H (Dec. 12/18)

Staff removed the towel and began using individual towels for the children during inspection.
Corrective Action(s):
Date to be Corrected:

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 (CORRECTED DURING INSPECTION): During inspection Licensing noted that some staff persons in the program were not aware of where a child's Epi-pen was being stored.

Staff added the location of the Epi-pen to the posted care plan to ensure all staff would be aware of it's location.
Corrective Action(s):
Date to be Corrected:

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: During inspection Licensing randomly sampled 10 children's records and noted that the start/ enrollment date was not recorded in them.
Corrective Action(s): Ensure start/ enrollment date is on file for all children in care.
Date to be Corrected: Nov. 28/19


Comments

At the inspection dated Oct 30, 2019 there were 37 children and 8 staff present. At this inspection the above noted contraventions were identified or no contraventions were identified.
Licensee to provide written documentation to Licensing once all violations have been corrected.
As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.
The following resources were provided:
- "Guidance in Disinfecting for Child Care Facilities" handout
During inspection Licensing observed:
- children in the 3-5 program engage in a circle time, have free use of Montessori equipment and have a free play time in the outdoor area.
- children in the < 36 month programs engage in free play in the outdoor play area as well as transitioning inside for lunchtime
- staff in all programs interacting with children while they were engaged in actvities as well as assisting with problem solving when necessary.

Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA, CCLR, and DLSP).

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 28, 2019

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