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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMIA-AP8QCV

FACILITY NAME
Roots & Wings Montessori Heritage House
SERVICE TYPES
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
FACILITY LICENSE #
NNAL-8KLMH5
FACILITY ADDRESS
15250 54A Ave
FACILITY PHONE
(604) 574-5399
CITY
Surrey
POSTAL CODE
V3S 8R7
MANAGER
Veronique Bodart

INSPECTION DATE
July 13, 2017
ADDITIONAL INSP. DATE (multi-day)
July 13, 2017
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
09:00 AM
DEPARTURE
11:00 AM
ARRIVAL
02:45 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
22

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 (DLSP). 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 the inspection.

The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

As part of this 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 operation.

Visit the CCFL website at www.fraserhealth.ca/childcare for:
· Additional resources, and
· Links to the Legislation (CCALA and CCLR)

Useful websites to consider:
· Criminal Record Checks: www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
· ECE Registry: www.mcf.gov.bc.ca/childcare/ece

Contraventions
Previous Inspection - Contraventions observed on FIR #JMIA-AHQVHM 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
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 a number of areas regarding the health and safety of the children, including;

Indoors:
- There were a number of tall shelves that were not secured to the wall, a number of these shelves also had excessive storage (including some heavier items) stored on top.
- Two electrical outlets were not covered
- A pair of adult scissors were left on the activity table " airport" that children were building
- There were no individual towels available for the children in the downstairs washroom, Licensing observed three children use this washroom while playing outdoors.

Outdoors:
- The resilient surface needs to be reshuffled to ensure it is an adequate depth under climbing equipment as Licensing could see bare ground under the spider type climber. A six foot fall zone is recommended.
- There were two areas inside the playyard that piled up of rubbish (boxes and hose) and a broken table with an old train set, that were awaiting to be removed. staff explained these were too heavy for staff to move.
- Two picnic tables in the play yard have pealing paint
- A ramp was being used by children on rideon toys, half way down a hose was laid across, causing bikes to have to bump over. This has potential for a tripping/falling hazard.
Corrective Action(s): Please ensure a healthy and safe environment at all times while children are in care.
Date to be Corrected: July 20, 2017

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: Hazardous Items observed within reach of children today include;
- A large paper slicer in the upstairs staff washroom/storage room - behind an unlocked door
- Lysol and Painter's Touch were found under the unlocked preschool sink cupboards
Corrective Action(s): Please ensure that children do not have access to any hazardous items.
Date to be Corrected: July 13, 2017

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: In the upstairs children's washroom, Licensing measured the water temperature at 58.1.
Corrective Action(s): Please ensure all water accessable to children is heated to no more than 49 degress Celsious.
Date to be Corrected: July 13, 2017

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: One staff file only had a list of three names and phone numbers that was titled "References", there was no indication that these references had be called/contacted to provide a character reference for the staff.
Corrective Action(s): Please ensure that all staff have checked character references on file.
Date to be Corrected: July 20, 2017

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: Two staff files were without a record of the person's work history.
Corrective Action(s): Please ensure staff files are current and complete.
Date to be Corrected: July 20, 2017

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: Licensing notes that one staff did not have immunization status on file.

Corrective Action(s): Please ensure staff files are current and complete.

Date to be Corrected: July 20, 2017

STAFFING: 12151 - CCLR s.19(5)(a) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (a) a criminal record check for the person.
Observation: One volunteer on site today did not have a CRC on site.
Corrective Action(s): Please ensure a current and complete file is available for all volunteers as per Section 19 (5)
Date to be Corrected: Before Volunteer returns to the facility.

STAFFING: 12152 - CCLR s.19(5)(b) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (b) character references in respect of the person.
Observation: No character references were available for review for the Volunteer who was on site today.
Corrective Action(s): Ensure a complete file is available for review.
Date to be Corrected: Before Volunteer Returns to the facility.

STAFFING: 12153 - CCLR s.19(5)(c) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs. .
Observation: No evidence of immunization status for the Volunteer.
Corrective Action(s): Please ensure immunization status is available for all volunteers prior to them being at the facility.
Date to be Corrected: Before the Volunteer returns to the facility.

STAFFING: 12210 - CCLR s.23(1)(a) - A licensee must ensure that children have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: During a review of staff files, Licensing noted that one staff was missing a valid First aid Certificate, The staff explained that this staff is only working in the capacity of a substitute and is not typically on site, Staff confirmed that two weeks ago the staff did work alone with a group of children at the end of the day for one hour.
Corrective Action(s): Please ensure that at all times children have immediate access to a staff that holds a valid first aid certificate.
Date to be Corrected: July 13, 2017

STAFFING: 12430 - CCLR s.56(1)(b) - A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements].
Observation: One staff's CRC had expired in April 2016.
Corrective Action(s): Please ensure a current CRC is on file.
If applied for online, please keep a copy of the submission receipt on file, while the Branch processes the application.
Date to be Corrected: July 20, 2017

POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must have all of the following: (b) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: Licensing notes that the fire extinguishers were due for their annual servicing on June 6, 2017
Corrective Action(s): Please ensure that fire extinguishers are serviced annually
Date to be Corrected: July 20, 2017

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: Licensing reviewed two Fire Drill Recording Sheets (one in each program) and observed the following;
- GCC- Nothing documented for the month of June and the months of March and May have an Earthquake Drill practiced and documented in the Fire Drill Section.
- PS- No Documentation of Fire Drills for the months of April, May and June.
Corrective Action(s): Please ensure that each month a fire drill is documented and conducted by all staff, even if you also choose to conduct an Earthquake Drill.
Reminder that although Earthquake Drills are not required by Licensing an Annual Emergency Evacuation drill is required.
Date to be Corrected: July 31, 2017

CARE AND/OR SUPERVISION: 14090 - CCLR s.40(2) - A licensee providing a care program described as Preschool (30 Months to School Age) must not provide care for more than 4 hours each day to each child.
Observation: The ECE staff described the current program being offered in the Licensed Preschool Program as a "Summer Camp" Licensing explained that Summer Camps are only offered to School Aged Children (as per Section 3 (1)(d)).
As the room is Licensed as a PS, the requirements of a PS Program must be maintained.
Licensing observed that some children are registered in an all day program (9-3), and besides going downstairs in the Licensed GCC program for Lunch, were described as being in the Licensed PS room from approximately 8:45-12 and then 1-3pm. This exceeds the maximum hours of care for a PS program.

Licensing notes that some of the children who are also physically in the upstairs program are actually registered in the daycare program (one child goes down to nap from 1-2ish) and return downstairs at 3-6pm approximately).
Corrective Action(s): Please ensure maximum hours of care for a PS program are not exceeded.

Date to be Corrected: July 14, 2017

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: During a review of 7 children's files Licensing observed;
- 5 Children without an MSP#
-4 Children without Immunization Status
Corrective Action(s): Please ensure children's files are current and complete.
Date to be Corrected: July 20, 2017

RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure.
Observation: During a review of attendance records for the month of July for both the PS program and Group Child Care licensing observed the following;
- Today had 2 children signed in the GCC and 7 children signed into the PS, however all children were together and there 10 children in attendance.
-July 5, 10 and 11th - were missing either sign in or sign out times.

Corrective Action(s): Please ensure attendance records accurately show time in, time out and what program the child is physically in attendance.

Date to be Corrected: July 14, 2017

RECORDS AND REPORTING: 19100 - CCLR s.57(2)(d) - A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Observation: Licensing observed 4 children's files without a medical practitioner's name or number.
Corrective Action(s): Please ensure staff files are complete.
Date to be Corrected: July 20, 2017

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: During a review of children's files Licensing noticed some of the children registered are without Photo's.
Corrective Action(s): Please ensure each child in attendance has a current photo or digital image.
Date to be Corrected: July 20, 2017


Comments

During today’s inspection two ECE staff, a volunteer, a parent and 10 children were on site. Licensing observed the following:
- Free play, outdoor play, circle time and snack time.

Discussed at time of this inspection with the ECE:
· Updated Child Care Licensing Regulations, including;
- Removing the requirement for pre-employment doctor’s letter
- Licensing notes that 2/3 of the staff files include a copy of validation. Licensee’s responsibility to validate and keep a record for all employees including substitutes, (both current and new hires) who hold a valid ECE Certification (ECE, ECE Assistant, I/T ECE & SN ECE).
· New Director of Licensing Standards of Practice for Active Play, including; Two new policies Active Play and Screen Use Policy, these policies must be created, implemented and provided to parents no later than September 1, 2017
- Mixing of groups- Licensing discussed ensuring service types are not mixing groups of children. Clear indication both in attendance and registration forms need to describe what service type (program) a child is in.
- Licensing explained that for all requirements of Section 19 need to be in place prior to any new staff being on site (re: substitute booked for next week).
- Discussed Storage of children's diapers/wipes and pull ups
- Creating care plans specific to each individual child.
- Creating a system to remove old children's files (Record Stop Date) and Staff Files from everyday storage (but remain on site).
- Ensuring (for each program) a Clear Start Date for each child is recorded
- Licensing discussed with the licensee the importance of regularly checking the fridge temperature to ensure that it is safe (between 0-4 degrees Celsius).
-Licensing spoke with Staff about using a bound book; with page numbers and answering questions "who, what, when, where and how" for all entries. Licensing further stated to ensure to initial or sign each entry; use one line to correct mistakes and initial after, any blank spaces should have a line thru it to ensure authenticity.
- During a review of the emergency supplies onsite, Licensing suggests on going assessment of supplies to ensure adequate supplies are in place (quality and quantity). The ECE staff explained that at the end of the preschool year most of the supplies were returned to the families, leaving a minimal amount in the PS program (more supplies available downstairs). Licensing suggests that there be enough supplies to last all children at least 72 hours.
- Licenseing initially reviewed 5 staff files as this is what was provided to Licensing when asked for staff files, upon review of the findings ECE staff indicated that 2 of these staff have not worked here for at least a year- Licesning recommends that this information be captured somewhere on the file.

Resources provided today include;
· Director of Licensing Standards of Practice for Safe Play
· Child Care Employees Immunization Status
· Summer Heat
· Emergency Kit Ideas
· Volunteer Requirements
· Children's Records - Child Care Links
· Licensing Update

Please provide a written response by July 21, 2017 addressing the contraventions identified above.
Due to the nature and number of contraventions a follow up inspection will be conducted in the near future.
This inspection report was written off site (2.25 hours included in the Time Spent )
This inspection was reviewed with the ECE staff prior to signing.
Thank you for your time and cooperation. Please contact me if you have any questions or concerns; a business card has been 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
Jul 21, 2017
Approximate Follow Up Date

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