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
KMBH-AS8SEY

FACILITY NAME
Play-N-Grow Childcare Centre
SERVICE TYPES
310 Multi-Age Child Care
FACILITY LICENSE #
BHAN-8ECP7X
FACILITY ADDRESS
13639 92nd Ave
FACILITY PHONE
(604) 782-3546
CITY
Surrey
POSTAL CODE
V3V 7J2
MANAGER
Asha Dhani

INSPECTION DATE
October 17, 2017
ADDITIONAL INSP. DATE (multi-day)
October 18, 2017
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:00 AM
DEPARTURE
11:30 AM
ARRIVAL
09:15 AM
DEPARTURE
10:15 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 (DOLSP). Evidence for this report was based on the Licensing Officer’s 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
As part of the routine inspection a Facility Risk Assessment Tool 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 http://www.fraserhealth.ca/childcare for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)
If you have any questions regarding this report feel free to contact me.
While on site, the following was discussed:
-The van that is used for transportation of children smelled of smoke. The Licensee stated that no one smokes in the van when children are in care. Some discussion was had with the Licensee about ensuring that no smoking occurs in the van at any point in time as it is used for the facility.
-An in depth discussion was had with the Licensee about creating an more accurate and in depth transportation policy for the parents. Additionally, a staff policy in regard to transportation and what is the protocol during emergency situations.
-Licensee does alot of business through the phone and texting with parents in order to arrange transportation. Licensee stated that there is no set schedule in regard to all pick ups as parents text when they are ready for the child to be picked up from their home, etc. At times, in the past, the Licensee has had to work on the floor as staff call in sick and the Licensee cannot find the appropriate sub staff. While on site today, Licensing brought up concern in regard to how the Licensee can provide care when they are constantly arranging transportation and talking with parents.
-Had a discussion with the staff about the use of equipment and whether it is age appropriate (i.e. intent and use of high chairs, should not be used as a form of restraint).
-A discussion about removing any unnecessary or repetitive documents and condensing the information within the children's files.
-The facility uses a lock at the top of the door. Licensing is concerned that this may be of concern with the fire department. Licensing recommends contacting them to ensure that this would be an acceptable practice.
-Had a discussion with the Licensee about updating the driver's information. The current driver's licence on file is expired.
-The facility does not carry all the emergency cards within the van. Please note that it is imperative that any child who is transported within the vehicle should have their emergency card readily available and accessible at all times in case of an emergency.

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: 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: The following were noted at the time of inspection:
-There is an ADT security sign that has been removed from the ground and is lying on the grass. The sign is attached to a piece of metal that could be hazardous to the children in care.
-There is a shelf within the circle room that is not attached to the wall and does not appear to be very sturdy. Additionally, there are some boxes that contain art that are stored on top of the book case that could be a topple hazard should a child decide to pull the box down.

Corrective Action(s): Please ensure a healthy and safe environment.
Date to be Corrected: October 24, 2017

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 wall within the nap room is still taped around the cleanout, a discussion had been had previously in regard to having the area around this pipe properly sealed (repeat).
-There is some small pieces of garbage within the outdoor play space, near the fence door on the left side.
Corrective Action(s): Please ensure facility is clean and in good repair.
Date to be Corrected: October 30, 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: There was no proof of verification of the staff's certificate for one of the staff who works at the centre.
Corrective Action(s): Please ensure that all staff who hold certificates (ECE & ECEA) have had their certificates verified and proof of verification is provided in order to confirm compliance.
Date to be Corrected: October 23, 2017

STAFFING: 12430 - CCLR s.56(1)(b) - A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements].
Observation: -One staff who waits with the children at a school while they wait to be picked up by the driver did not have a file on site. The Licensee stated that they had a complete file, however, it was stored within the van.
-One staff does not have a site specific criminal record.
Corrective Action(s): A discussion was had in regard to ensuring that all staff files are accessible in order to confirm that they have a complete file.
-Please ensure that all staff have site specific criminal record checks.
Date to be Corrected: October 23, 2017

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: There has not been a standard of practice for active play policy created.
Corrective Action(s): Please refer to the standard of practice for active play guideline, create an active play policy, implement and distribute to the parents. Please submit your policy to Licensing for review.
Date to be Corrected: October 23, 2017

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: The facility has not yet created a screen time policy.
Corrective Action(s): Please refer to the standard of practice for active play guideline, create a screen time policy, implement and distribute to the parents. Please submit your policy to Licensing for review.
Date to be Corrected: October 23, 2017

CARE AND/OR SUPERVISION: 14060 - CCLR s.39(1) - A licensee must ensure that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.
Observation: There is a sibling group who is dropped off by parents so that they can be transported to school. Two children are enrolled in the daycare program, however, the older child is not enrolled. As the child is not enrolled in the program, they sit in the van until the driver for the facility takes them to school (about 10 minute wait). Licensee was unsure as to how old the child was but suspected that they were in grade 5 (i.e. "old enough to sit in the car alone"). Upon review of the attendance forms, it was determined that this same child has been signed into the daycare and has been in attendance at the daycare. As the child is sitting in the daycare vehicle, parked on the premises, they are considered to be in care and therefore, the child has been left unsupervised in the van.
Corrective Action(s): Please ensure supervision of all children in care at all times.
Date to be Corrected: October 18, 2017

CARE AND/OR SUPERVISION: 14360 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: The Licensee has three facilities, at 4:30, two facilities close, as the Licensee stated that there is no need to have so many staff working with a small number of children. The children are then transported to this facility and are picked up or driven home by the facility's driver at a later time. Additionally, there are multiple children who are dropped off at this site in the morning and are then transported to their priority daycare within 10-30 minutes of being dropped off at this centre. In depth discussion has been had with the Licensee over the years in regard to the moving of children to multiple facilities and it not being in their best interest. All programs need to be considered separate entities and if a child is enrolled within one centre, the expectation is that the child spends the day at the centre and is not transported to another location for convenience.
-Upon review of the transportation information, Licensing noted that there are at least 20 children who are driven to different locations throughout the day. Licensing discussed the concerns about distracted driving and continuous calls to the driver of the car advising of their next pick up when they are driving with children in the car. Licensing has asked that the facility at the very least a create a weekly schedule written out on paper which indicates when children need to be picked up, dropped off, etc. It appears as though the regular communication with parents could get in the way and possibly hinder the quality of care and safety of the children at the facility.
Corrective Action(s): Please ensure that the facility operates in a manner that promotes the health safety and dignity of the children in care at all times. Please submit a written schedule that includes all stops for all the children who are transported by the facility.
Date to be Corrected: October 18, 2017

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: 19 children's files were reviewed and 8 were missing immunization information.
Corrective Action(s): Please ensure that children's files are complete.
Date to be Corrected: October 23, 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: 19 children's files were reviewed, 3 were missing a start date.
Corrective Action(s): Please ensure children's files are complete.
Date to be Corrected: October 23, 2017

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: Upon review of attendance - the following was noted:
On October 10, 12, 13 & 17 some children were either not signed in or out of the facility. Some children had a sign out time that came before the sign in time.
Corrective Action(s): Please ensure that attendance is accurate and complete.
Date to be Corrected: October 17, 2017

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: 19 children's files were reviewed - 6 were missing Dr information, 2 were missing emergency contact.
Corrective Action(s): Please ensure children's files are complete.
Date to be Corrected: October 23, 2017

RECORDS AND REPORTING: 19160 - CCLR s.57(2)(i) - A licensee must keep, for each child, a record showing the following information: (i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency.
Observation: 19 children's files were reviewed and 3 were missing photos. Please note that some of the photos on file are of poor quality and need to be updated.
Corrective Action(s): Please ensure that all children have a photo (which is of good quality).
Date to be Corrected: October 18, 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: There is a child on site who requires extra support and has a support worker who attends the daycare regularly. The facility did not have a care plan in place for this child.
Corrective Action(s): Had a discussion in regard to obtaining the details of the care plan or creating a care plan for the child. The facility needs to be proactive at ensuring that the techniques used by the support worker are used every day when the child is at the facility (i.e. following the care plan).
Date to be Corrected: October 23, 2017

RECORDS AND REPORTING: 19320 - CCLR s.59(a) - In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58.
Observation: Upon review of attendance, 4 children who attended this daycare did not have a file on site. Licensee stated that they are kept at another facility. Discussion was had about having attendance records for all children who are in care within the facility.
Corrective Action(s): Please ensure that all children who attend the daycare have a complete file accessible at the facility.
Date to be Corrected: October 23, 2017


Comments

Please provide a written response indicating how you will address the violations noted above as well as the updated policies and transportation schedule by Tuesday October 24, 2017

Thank you for your time today.

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 23, 2017

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