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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-AWZPZT

FACILITY NAME
Frog Hollow Montessori House
SERVICE TYPES
302 Group Child Care (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
NGIL-8DEUY5
FACILITY ADDRESS
529 Queens Ave
FACILITY PHONE
(604) 521-1355
CITY
New Westminster
POSTAL CODE
V3L 1K2
MANAGER
Helene Kell

INSPECTION DATE
March 19, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
09:30 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
54

Introduction

An unscheduled routine inspection of this community care facility (CCF) was conducted by the licensing officer (FHA) to assess compliance w/ the:
• Community Care & Assisted Living Act (CCALA)
• Child Care Licensing Regulation (CCLR)
• Director of Licensing Standards of Practice (DLSP; Active Play & Safe Play Space)

At the time of inspection, evidence for this facility inspection report (FIR) was based upon:
• FHA's observations
• FHA's review of the CCF's records
• information provided to FHA by employees

FHA reviewed these 10 areas today:
• licensing • hygiene & communicable disease control
• physical facility • medication
• staffing • nutrition & food services
• policies & procedures • program
• care & supervision • records & reporting

As part of this inspection, FHA completed & provided a risk assessment tool, which includes:
• any noncompliance identified • the CCF's compliance & operational history since 19/Mar/2015

Contraventions
Previous Inspection - Contraventions observed on FIR #CGEE-AKHP6E 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
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: 2 employees lacked a copy of their CRC in their file.
Corrective Action(s): Please ensure that all requirements of sec. 19(1) are obtained by employees' 1st day of employment.
Date to be Corrected: 16/Apr/2018

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 (CORRECTED DURING INSPECTION): An employee lacked evidence of her ECE certificate validation.
Corrective Action(s):
Date to be Corrected:

STAFFING: 12160 - CCLR s.20(1) - The licensee must not permit a person over the age of 12 to be ordinarily present on the premises of a community care facility while children are present, unless the person is of good character and the licensee has obtained a criminal record check for that person.
Observation: The licensee didn't obtain a student's CRC prior to allowing her to be present in the CCF.
Corrective Action(s): Please ensure that all ordinarily present individuals > age 12 have a CRC prior to being ordinarily present.
Date to be Corrected: 16/Apr/2018

STAFFING: 12470 - CCLR s.60(4) - Immediately after a person who was the subject of a character reference is no longer employed by or ordinarily present at the community care facility, a licensee must return all character references to the person, or destroy the character references.
Observation (CORRECTED DURING INSPECTION): A former employee's references were still in her file.
Corrective Action(s):
Date to be Corrected:

POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Observation: The manager & employees stated that fire drills are practiced monthly & emergency drills are practiced annually. However, they were unable to find the documentation.
Corrective Action(s): Please ensure that these training practices are documented.
Date to be Corrected: 30/Mar/2018

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: 2 children's care plans weren't signed & dated.
Corrective Action(s): Please ensure that children's care plans are reviewed annually w/ a parent, & then signed/dated by the parent.
Date to be Corrected: 22/Mar/2018

RECORDS AND REPORTING: 19370 - DLSOP Safe Play Space (maintenance of equipment [b3]) - [bullet 3] Keep a log of all inspections, maintenance and repairs.
Observation: Re. the outdoor play space, inspections (daily/monthly/annual), maintenance, & repairs aren't documented.
Corrective Action(s): Please ensure the abovementioned items are documented. The manager printed the DLSP (SPS) today for her reference. This requirement is on pg 3/10.
Date to be Corrected: 20/Mar/2018


Comments

FHA:
• reviewed this FIR w/ the manager prior to signing & printing • thanks all employees for their time & assistance today

Please visit http://www.fraserhealth.ca/childcare/ for:
• links to the CCALA, CCFL,& DLSP
• the temporary placement/retention application form • the exemption application form
• additional resources

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
Mar 26, 2018

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