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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MPEE-DDLSM8

FACILITY NAME
CEFA Early Learning Surrey - Nordel
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
LSEO-B5UTZG
FACILITY ADDRESS
200 - 8820 120th St
FACILITY PHONE
(778) 368-7608
CITY
Surrey
POSTAL CODE
V3V 0C9
MANAGER
Huong (Linda) Canosa

INSPECTION DATE
February 05, 2025
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.75
ARRIVAL
08:15 AM
DEPARTURE
12:00 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) and the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DoLSoP). All care categories 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:
- There is paint chipping on the window sills and walls of all classrooms. The drywall is now exposed posing a hazard to the children.
- Various equipment stored in the children's bathrooms (i.e art trolly, play tent etc.)
- Cleaning solutions were accessible in the GCC (under 36 mos) classroom
Corrective Action(s): Ensure there is a system to maintain a healthy and safe environment
Date to be Corrected:

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: Licensing observed the following:
- The railing on 2 baby cribs are chipping, exposing the plywood underneath. The surface is now porrous and cannot be cleaned and sanitized effectively.
- 1 play pen with holes on the netting
- Casing around the door in the GCC (under 36 mos) classroom is broken
- High touch surfaces such as door knobs and bathroom doors are dirty
- Change pad in the GCC (30 mos to SA) classroom is dirty
Corrective Action(s): Ensure there is a system to ensure the facility is clean and in good repair.
Date to be Corrected:

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: A random selection of staff files were reviewed. Out of the 5 reviewed, 3 did not have verified references.
Corrective Action(s): Ensure staff files are complete.
Date to be Corrected:

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 system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: A random selection of staff files were reviewed. Out of the 5 reviewed, 3 did not have validated certificates.
Corrective Action(s): Ensure staff files are complete.
Date to be Corrected:

CARE AND/OR SUPERVISION: 14180 - CCLR s.48(7) - A licensee must ensure that food and drink are not used as a form of reward or punishment for children.
Observation: Licensing observed in the GCC (30 mos to SA) classroom a child sitting at the table with no snack in front of him asking for banana, while all other children had their snack placed in front of them. This was observed for several minutes. A staff told Licensing the child was not allowed to eat until he put a toy away.
Corrective Action(s): Ensure food and drink are not used as a form of reward or punishment.
Date to be Corrected: February 5, 2025

MEDICATION: 16010 - CCLR s.53(1)(a) - 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 (a) administered to the child in the amount and at the times specified by the child's parent or in the child's record or care plan.
Observation: Licensing observed the following:
- Staff said medication was administered to a child, however cannot recall recording the amount and time administered.
- There were no written directions specified by the parents or careplan regarding the administration of medication.
Corrective Action(s): Ensure there is a system for administering and recording medication.
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: - Emergency medication was expired.
Corrective Action(s): Ensure there is a system to ensure medication is not expired.
Date to be Corrected:

MEDICATION: 16050 - CCLR s.53(3)(a) - A licensee must ensure that at all times an employee is available who is competent to either (a) administer a child's medication as instructed by the child's parent or required by the child's record or care plan.
Observation: A staff was unsure where emergency medication was stored for a child.
Corrective Action(s): Ensure all staff are familiar with all children requiring specialized care.
Date to be Corrected:

RECORDS AND REPORTING: 19250 - CCLR s.58(2)(a) - The licensee must (a) develop the care plan in consultation with a parent of the child requiring extra support and any person requested by the parent.
Observation: Licensing observed 3 children did not have a care plan that was developed in consultation with the parent or any person requested by the parent.
Corrective Action(s): Ensure there is a system to create care plans for children requiring specialized care.
Date to be Corrected:

RECORDS AND REPORTING: 19260 - CCLR s.58(2)(b) - The licensee must (b) review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Observation: Licensing observed 2 care plans were not reviewed annually with the parent or any person requested to by the parent.
Corrective Action(s): Ensure all care plans are reviewed annually.
Date to be Corrected:


Comments

Summary of Inspection:
At the inspection dated February 5, 2025 there were 48 children in care with 13 staff, 1 support staff, 3 practicum students and the Manager.
At this inspection the above noted contraventions were identified.
Action required by the Licensee is to provide Licensing with a written response by February 12, 2025.
Action required by Licensing is to review the written response.

The following discussions were had:
The center has several surveillance cameras located throughout the facility. It appears some of the cameras have a view of the children's bathrooms. Licensing discussed with the Manager and Licensee contact all cameras that are recording the bathrooms need to be immediately disabled and moved or pointing away from the bathroom areas.
Emergency medication is coming to expire
A review with staff regarding children's dietary restrictions or religious preferences versus an allergy
Separate disinfecting bottles for bathrooms and diaper change stations
Label all spray bottles including ones with soap and water
There is good documentation in the Minor Incident Log Book. Licensing reminded staff to ensure when documenting to capture the 5 W'S (who, what, where, when, why)

As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy was provided to the facility along with this report. The Risk Assessment includes any non-compliance identified during the routine inspection and a 3 year ‘historical’ review of the facility’s compliance and operation and is used to determine inspection frequency.

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

Please contact me if you have any questions or concerns.

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
Feb 12, 2025

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