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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MPEE-BHLSN7

FACILITY NAME
1st Step Montessori Inc - Sunbury Hall
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
MLAO-A92NPK
FACILITY ADDRESS
10409 Dunlop Rd
FACILITY PHONE
(604) 417-3290
CITY
Delta
POSTAL CODE
V4C 2L1
MANAGER
Randeep Bal

INSPECTION DATE
November 04, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
10:15 AM
DEPARTURE
02:45 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 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: 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: Licensing observed the following:
- In the outdoor playground the green mats used for resilient surfacing is becoming a tripping hazard for the children.
- In the children's bathroom there is a garbage bag in the drawer accessible to the children
- There are electrical cords accessible to the children in the preschool and three to five program
- In the three to five and infant and toddler classroom there is a stereo that is not secured placed on the ledge posing a risk to the children.
Corrective Action(s): Please ensure a healthy and safe environment is provided at all times.
Date to be Corrected: November 12, 2019

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: - In the outdoor playground the square soft puzzles used for resilient surfacing is showing signs of wear and tear.
- In the preschool room the wooden flooring is worn in some areas posing as a risk for splinters.
Corrective Action(s): Please ensure fixtures are clean and in good repair.
Date to be Corrected: November 12, 2019

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: A selection of staff files were reviewed. Out of the seven files reviewed one file did not have a criminal record check available. Out of the seven files reviewed two files had criminal record checks addressed to another facility.
Corrective Action(s): Please ensure a valid criminal record check is on file.
Date to be Corrected: November 12, 2019

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: A selection of staff files were reviewed. Out of the seven files reviewed one file did not have a resume.
Corrective Action(s): Please ensure a record of the employee's work history is on file.
Date to be Corrected: November 12, 2019

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: A selection of staff files were reviewed. Out of the seven files reviewed three files were missing an immunization record.
Corrective Action(s): Please ensure an immunization record is on file.
Date to be Corrected: November 12, 2019

CARE AND/OR SUPERVISION: 14020 - CCLR s.34(2)(a) - Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.
Observation: Licensing observed some children enrolled in the preschool were also enrolled in the daycare. However, during outdoor playtime some children were dropped off into the daycare and some children stayed with the preschool. At this time the preschool was still in session. It was noted that when one child that was dropped off into the daycare capacity was exceeded by one child , staff obsevered this and escorted the child back to the preschool. Sign in and out is not taking place therefore there is no clear documentation indicating when transfer of care occurs. A discussion was had with the licensee to ensure attendance includes times on when the children were dropped off into preschool and then when they returned back to the daycare.
Corrective Action(s): Please ensure that children attending a CCF are divided into groups and that group size and staff to child ratio follows Schedule E
Date to be Corrected: November 12, 2019

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: A random selection of childrens files were reviewed. Out of the six files reviewed one file had a missing care card number.
Corrective Action(s): Please ensure a valid care card number is kept on file.
Date to be Corrected: November 12, 2019

RECORDS AND REPORTING: 19140 - CCLR s.57(2)(h)(i) - A licensee must keep, for each child, a record showing the following information: (h) any special instruction respecting the child's diet, medication, participation in a program of activities, or other matter relevant to the child's care, (i) given by the child's parent to the licensee in writing.
Observation: There is a care plan in place for a child enrolled in the program. However, in discussion with the licensee the medication is no longer being provided as it is no longer needed.
Corrective Action(s): Please ensure any special instructions respecting the child's medication relevant to the child's care, given by the child's parent is in writing.
Date to be Corrected: November 12, 2019


Comments

At the inspection dated November 4, 2019 there were 26 children and 5 adults present. At this inspection the above noted contraventions were identified.
Action required by the licensee includes providing a written response by November 12, 2019.
Actions required by licensing include review the written response and due to the nature of the contraventions a follow-up will be conducted.
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.
The following discussions were provided:
-The School Age program has not been in operation since March 2019. A discussion was had with the licensee that an Amendment to the license would need to be made after one year of a program not being in operation.
- Licensing observed children use hand sanitizer before snack time. A discussion was had with the licensee to ensure effective hand washing was done using running water and soap while in the facility.
- A discussion was had with the licensee to submit a schedule for outdoor play time for all three programs as there is only two playgrounds. One specifically for infant and toddlers and a shared playground for the three to five and preschool program. This is to ensure children are getting the appropriate active play time as per the Director of Licensing Standards of Practice for Active Play.
The following resources were provided and reviewed:
- Child Safety Alert
- Incident Reporting April 2019
- Application to Amend Existing License
- Facility Staffing Plan
- Reportable Incident Form
- Staff Qualifications/ Documentation
Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).
If you have any questions regarding this report feel free to contact your licensing officer. A business card was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Due Date
Nov 12, 2019
Approximate Follow Up Date
19 Nov, 2019

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