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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMIA-CYGTC4

FACILITY NAME
Alexandra Neighbourhood House Children's Centre at Crescent Park
SERVICE TYPES
306 School Age Care on School Grounds
FACILITY LICENSE #
KPUL-BHLN44
FACILITY ADDRESS
2440 128th St
FACILITY PHONE
(778) 239-4697
CITY
Surrey
POSTAL CODE
V4A 3W3
MANAGER
Nita Pedersen

INSPECTION DATE
December 13, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.25
ARRIVAL
02:45 PM
DEPARTURE
04:15 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: Staff have been using only soap and water to clean and sanitize tables and equipment. A disinfectant product is available on site but only used for the occasional deep clean when needed. .
Corrective Action(s): Sanitizing of tables and equipment is required after use to reduce cross contamination of germs.
Date to be Corrected:

STAFFING: 12190 - CCLR s.22(2)(b) - A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.
Observation: The fire drill documentation drill was not practiced in the month of October. This was not documented on the record sheet and confirmed by staff.
Corrective Action(s): Please ensure a fire drill is practiced by all staff each month.
Date to be Corrected:

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: Staff have yet to practice the annual evacuation drill, the last one was practiced in August 2022. Staff has recently inquired with management and the school in regards to the details of the evacuation plan and plans on conducting the drill during winter break.
Corrective Action(s): Please ensure an annual evacuation drill is conducted by all staff.
Date to be Corrected:

STAFFING: 12450 - CCLR s.60(3)(a) - A licensee must keep (a) in the case of employees, all records required under section 19 (1) [character and skill requirements] for the entire time that the subject of the records is an employee of the community care facility.
Observation: Two staff files were reviewed, one regular staff's records were not documented including; Criminal Record Check, Immunization Status, Character References & Resume.
Corrective Action(s): Ensure staff record information is available on site
Date to be Corrected:

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: Although attendance records are being recorded daily, not all information is accurately being recorded. Children who arrive before school are not signed out and are not resigned in after school.
Corrective Action(s): Please ensure children are accurately signed in each day.
Date to be Corrected:


Comments

Summary of Inspection:

At the inspection dated December 13, 2023 there were 13 children and two staff present.
At this inspection the above noted contraventions were identified.
Action required by the licensee includes providing a written response by December 21, 2023
Actions required by Licensing include reviewing the written response and conducting a follow up inspection.

As part of this Routine Inspection, a Facility Risk Assessment Tool was completed.

The following discussions were had;
- Active Supervision- practices
- Increase in enrollment no longer have enough hooks for children's storage
- Ongoing updating of files to capture new information such as immunization updates or photos to ensure a child is readily identifiable in an emergency
- Log books- injuries, illnesses and unusual events (also document when parents notified)
- Products with DIN#'s are inside the first aid kit, staff doesn't use on children
- Reportable Incident Reporting –Duty Line 604-587-3936.

The following resources to be emailed;

· Bleach resources

This inspection report was reviewed with the staff and a copy of both the report and Risk Assessment were provided to the facility at the time of inspection.
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 LicensingFollow-up Inspection Required
Due Date
Dec 21, 2023
Approximate Follow Up Date

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