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

FACILITY NAME
Rising Stars Daycare Inc
SERVICE TYPES
310 Multi-Age Child Care
FACILITY LICENSE #
BHAN-BHGMFH
FACILITY ADDRESS
8094 11th Ave
FACILITY PHONE
(604) 553-9987
CITY
Burnaby
POSTAL CODE
V3N 2N7
MANAGER
Enola Medina

INSPECTION DATE
December 13, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.5
ARRIVAL
03:15 PM
DEPARTURE
04:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
13

Introduction

Community Care Facilities Licensing (CCFL) inspected all care categories during an unscheduled routine inspection to assess compliance w/:
• the Community Care & Assisted Living Act
• the Child Care Licensing Regulation
• relevant Director of Licensing Standards of Practices

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: In the outdoor play space, there was a wooden table on its side. Its splintery legs faced out & are some children's height.
Corrective Action(s): The table must be placed right side up or removed altogether.
Date to be Corrected: 14/Dec/2023

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11190 - CCLR s.16(4)(b) - A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.
Observation: There was only 1-2' clearance @ the end of each slide.
Corrective Action(s): 6' use zones in all directions allow for proper use of the equipment, w/ adequate space for entering & exiting.
Date to be Corrected: 20/Dec/2023

STAFFING: 12200 - CCLR s.22(2)(c) - A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.
Observation: Repeat violation from FIR #CGEE-CT9NSP (29/Jun/2023): The last emergency drill was practiced in Feb/2022.
Corrective Action(s): The emergency drill must be practiced every 12 months.
Date to be Corrected: 22/Dec/2023

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 (CORRECTED DURING INSPECTION): Repeat violation from:
- FIR #CGEE-CFLQPV (21/Jun/2022)
- FIR #CGEE-CT9NSP (29/Jun/2023)
- complaint investigation (02/Nov/2023)
1 of the rooms had 5 children age 4 yrs (1), 2.75 yrs (1), & 1.5 yrs (3).
Corrective Action(s): MACC only permits ≤ 3 children < 36 months in a group. The manager moved the 2.75-yr-old child to another room where all children were > 3 yrs.
Date to be Corrected:

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: A child's EpiPen expired in Apr/2023 & another child lacked an EpiPen despite her record stating she requires 1.
Corrective Action(s): A valid EpiPen must be obtained for both children.
Date to be Corrected: 15/Dec/2023

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: Repeat violation from FIR #CGEE:
- BPLM2B (13/May/2020)
- CT9NSP (29/Jun/2023)
A child lacked his immunization status.
Corrective Action(s): All requirements of CCLR s.57 must be obtained by children's 1st day of care.
Date to be Corrected: 20/Dec/2023

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: Repeat violation from FIR #CGEE:
- BPLM2B (13/May/2020)
- CT9NSP (29/Jun/2023)
3 children's start dates were undocumented.
Corrective Action(s): All requirements of CCLR s.57 must be obtained by children's 1st day of care.
Date to be Corrected: 20/Dec/2023

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: Repeat violation from FIR #CGEE:
- CFLQPV (21/Jun/2022)
- CT9NSP (29Jun/2023)
A child lacked a physical or digital photograph.
Corrective Action(s): All requirements of CCLR s.57 must be obtained by children's 1st day of care.
Date to be Corrected: 20/Dec/2023

RECORDS AND REPORTING: 19190 - CCLR s.57(3)(a) - A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached.
Observation: Parental consent for emergency care was missing for 1 child.
Corrective Action(s): All requirements of CCLR s.57 must be obtained by children's 1st day of care.
Date to be Corrected: 20/Dec/2023

RECORDS AND REPORTING: 19210 - CCLR s.58(1)(a) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (a) the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.
Observation: A care plan was missing for a child requiring extra support.
Corrective Action(s): A care plan is required for any children requiring extra support.
Date to be Corrected: 18/Dec/2023

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: 2 employees lacked their documentation which was previously onsite.
Corrective Action(s): Employee documentation must remain onsite.
Date to be Corrected: 20/Dec/2023


Comments

Summary
11 violations were observed, in which 1 violation was corrected during the inspection. Corrective action for the remaining 10 violations includes:
• obtaining 2 employees' files
• practicing the annual emergency drill
• obtaining medication for 2 children requiring extra support
• obtaining children's records

Websites of interest
• Appetite to Play: www.appetitetoplay.com
• BCCDC Public Health Guidance for Communicable Disease Management in Child Care Settings: www.bccdc.ca/Health-Info-Site/Documents/COVID_public_guidance/Guidance_Child_Care.pdf
• BCMJ Criminal Records Review Program: www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
• FHA CCFL Resources for Licensees & Managers: www.fraserhealth.ca/health-topics-a-to-z/child-care/resources-for-child-care-operators
• HealthLinkBC Files: www.healthlinkbc.ca/services-and-resources/healthlinkbc-files
• VCH Sneezes & Diseases: https://sneezesdiseases.com/assets/uploads/1589214601pDsukixOst24Mk9wayE3eA9Jjji7.pdf

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, 2023
Approximate Follow Up Date

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