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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
DCAR-AG2VWH

FACILITY NAME
Fraser Valley Montessori Preschool and School Age Care
SERVICE TYPES
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
TBIU-8W9SWN
FACILITY ADDRESS
3060 Old Clayburn Rd
FACILITY PHONE
(604) 859-8410
CITY
Abbotsford
POSTAL CODE
V2T 4M7
MANAGER
Jennifer Weisner

INSPECTION DATE
November 18, 2016
ADDITIONAL INSP. DATE (multi-day)
November 21, 2016
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
03:15 PM
DEPARTURE
05:00 PM
ARRIVAL
09:00 AM
DEPARTURE
10:30 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)

Live 5210 starter kit and information was provided and discussed


Should you have any questions pertaining to this report please feel free to contact me
Licensing Officer
Community Care Facilities Licensing


Contraventions
Previous Inspection - Contraventions observed on FIR #DCAR-A8LQ9W 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: 10010 - CCLR s.10(1) - Applicants for licences and licensees must notify a medical health officer immediately of any change in the information provided under section 9.
Observation: It was noted that a child who attends the School-age Program arrives when the preschool program is still in session. Staff stated that they wait outside in the playground with the child or within the school. It was determined based on review of attendance records that the arrangement is recurring. Posted within the facility licence is a term which includes that programs are not to operate concurrently.Child arrives at 2:15 PM while the school-age program begins at 2:45 as stated by staff. Section 7 (1) (b) of the CCALA - Standards to be maintained includes that care must be provided that promotes the child's health , safety and dignity. While it is clear that the staff provided care and supervision to the child it was however unreasonable to expect that the child could not attend or begin indoor programming ( waiting for the bell to ring ) for an estimated 30 mins.
Corrective Action(s): A licensee must provide immediate notification to any change in the information which was provided which would include business hours of operation.
Date to be Corrected: Nov 22, 2016

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11080 - CCLR s.15(1)(a) - A licensee must supply equipment, furniture and supplies that are (a) of sturdy and safe construction, easy to clean and free from hazards.
Observation: A wooden sandwich / sign board was stored beside the washroom door which protruded into the point of entry reducing space for a child to enter and exit and poses risk of potential injury as it is at eye level. A contravention to stored items in this area has been found in the previous inspection.
Corrective Action(s): Please ensure equipment is stored in such a way that it promotes child's safety - free from hazards
Date to be Corrected: Nov 22, 2016

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 (CORRECTED DURING INSPECTION): 1 exposed electrical outlet was accessible to the children , cleaning supplies stored on a unlocked closet on a shelf a chair was positioned in the area. Staff stated that the closet it normally secured by that the key was misplaced.Medications were observed stored within a child's backpack in the cubby area as observed by Licensing when the child accessed the pack. Staff was unaware of the existing medications.
Corrective Action(s): please ensure children do not have access to any object or substance that may be hazardous to their health and safety.
Date to be Corrected: Nov 22, 2016

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11230 - CCLR s.47 - A licensee must ensure that any heated water accessible to children is heated to no more than 49° Celsius.
Observation: Hot water at the sink accessed by children recorded temperature of 49.8 Celsius
Corrective Action(s): please ensure in order to reduce risk of scalding that children do not have access to water which exceeds 49C
Date to be Corrected: Nov 22, 2016

STAFFING: 12180 - CCLR s.22(2)(a) - A licensee must ensure that each employee (a) is trained in the implementation of the fire drill system and emergency plan described in subsection (1), including the use of any equipment noted in the fire drill system and emergency plan.
Observation: 1 staff working independently with children was unable to provide details of the fire plan. The fire drill system was posted on the wall and identified the evacuation location however the staff was unfamiliar with this including that she had not participated in a fire drill with children.
Corrective Action(s): A licensee must ensure that each employee is trained in the implementation of both the emergency plan and the fire drill system.
Date to be Corrected: Nov 30, 2016

STAFFING: 12220 - CCLR s.23(1)(b) - A licensee must ensure that children have at all times immediate access to an employee who (b) is knowledgeable respecting each child's medical condition, if any.
Observation: Care Plans posted within the facility detail information pertaining to children's medical condition, when requesting information such as medication storage in support of 1 care plan the staff was unable to locate the medication. The staff was unaware of medications which were provided by the family for their child. The medication was located on day 2 of the inspection as the facility manager stated that it was pushed further back onto a shelf within the supplies cupboard.
Corrective Action(s): Please ensure staff are knowledgeable respecting each child's medical needs , storage of medications.
Date to be Corrected: Nov 30, 2016

POLICIES AND PROCEDURES: 13040 - CCLR s.56(a) - A licensee must keep current records of each of the following: (a) written policies and procedures for the safe release of children.
Observation: a practice is in place where children may be picked up from the facility by other families for the purpose of play dates. Written policies in place direct staff in practices to following when releasing children from their care. The individuals picking up the children are not listed within the children's registration ( authorized to pick up )
Corrective Action(s): Please ensure staff are aware of and implement the facilities policies as per section 56 ( 2 ) of the CCLR.
Date to be Corrected: Nov 30, 2016

RECORDS AND REPORTING: 19030 - CCLR s.55(2)(a) - A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee.
Observation: An incident occurred which met the definition of missing / wandering , this incident was not reported to Licensing.
Corrective Action(s): A licensee must notify Licensing within 24 hours when a child is involved in a reportable incident as described in Schedule H of the Child Care Licensing Regulation. Additional time spent on site ( day 2 ) in review of reporting requirements.
Please ensure staff are familiar with the facilities reporting procedures.
Date to be Corrected: Nov 30, 2016

RECORDS AND REPORTING: 19060 - CCLR s.57(1)(a)(b)(c) - A licensee must keep current records for each child showing (a) the information set out in subsection (2),
(b) if applicable, the information and agreements set out in subsections (2.1) and (2.2), and
(c) the consents referred to in subsection (3).
Observation: One child's file was found to be outdated including information no longer relevant as stated by staff. The child has been in care for many years and the information has not been updated.
Corrective Action(s): Please ensure children's information is relevant / kept current.
Date to be Corrected: Nov 30, 2016

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: Several special arrangements in place for participation of programs on and off site. These arrangements are not documented.
Corrective Action(s): please ensure children's registration records are complete and include a record showing any special instructions respecting the children in your care.
Date to be Corrected: Nov 30, 2016

RECORDS AND REPORTING: 19150 - CCLR s.57(2)(h)(ii) - 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 (ii) agreed to by the licensee.
Observation: Special arrangements in place for several children attending however no record in place reflects that these arrangements are agreed to by the licensee.
Corrective Action(s): please ensure records reflect those arrangements agreed to be carried out by the licensee.

Date to be Corrected: Nov 30, 2016

RECORDS AND REPORTING: 19310 - CCLR s.58(3)(e) - The licensee must record compliance with the care plan of a child requiring extra support in respect of each of the following that are applicable to the child: (e) any other matter for which the licensee has agreed with the parent of the child to record compliance.
Observation: Very limited information recorded within a care plan , discussed ensuring matters for which the licensee has agreed with the parents are recorded. It is evident through observation that modification to programming would be a part of the care plan yet no information is included.
Corrective Action(s): please ensure compliance with the care plan is recorded for any matter for which you have agreed to carry out as requested by the parents.
Date to be Corrected: Dec 5, 2016


Comments

The inspection report was completed off site and arrangements were made to meet with the licensee contact to review the report at the CCFL office Nov 28th at 10:00 am
The identified contraventions were reviewed with the facility manager verbally at the conclusion of the inspection.
During day 1 of the inspection children were observed watching a movie ( 1 hour ) staff included that movies occur every Friday and on Pro - D days. It was noted that not all the children were interested in watching the movie yet activities were not set out for them. One child sat in the cubby area for over 1 hour with very little attempts by the staff to encourage participation in another activity.
It was observed that rather than being engaged with the children that the staff cleaned the facility with chairs stacked on top of tables. A shelf of school-age supplies and equipment was located in the cubby area however was covered with a sheet and did not appear available for use.
This observation was discussed with the facility manager as it would be expected that the children would be provided with activities during hours of operation.
Discussed future requirement for the development of a Screen Time Policy in addition to Active Play - Resources 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
Dec 20, 2016
Approximate Follow Up Date
19 Jan, 2017

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