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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EGAU-AVKPXB

FACILITY NAME
Best Friends Children's Centre Inc
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
TDAH-9EAVJC
FACILITY ADDRESS
106 & 201 - 19141 Ford Rd
FACILITY PHONE
(604) 457-1211
CITY
Pitt Meadows
POSTAL CODE
V3Y 2P8
MANAGER
Stephanie Hill

INSPECTION DATE
January 31, 2018
ADDITIONAL INSP. DATE (multi-day)
February 01, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
09:00 AM
DEPARTURE
04:45 PM
ARRIVAL
04:15 PM
DEPARTURE
04:45 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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 inspection.

Licensing conducted the inspection on January 31, 2018 from 9:00 a.m. to 10:30 a.m. Licensing returned to the facility to finish the inspection on January 31, 2018 from 2:30 p.m. to 4:45 p.m.

Licensing reviewed and delivered the report on February 01, 2018 from 4:15 p.m. to 4:45 p.m.

The following areas were reviewed:

· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Program
· Records and Reporting

As part of the 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 and operation.
Visit the CCFL website at http://www.fraserhealth.ca/childcare for:

· Additional Resources and
· Links to the Legislation (CCALA & CCLR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: During observation of the school age program, hot water was being boiled in a water kettle that was stationed on a countertop within the reach of children. A staff member was standing in the area but children were still accessing the counter. Licensing expressed scalding concerns if the water kettle was accidentally knocked down as it was in an area trafficked by children.
Corrective Action(s): Please ensure that children do not have access to boiling water.
Date to be Corrected: January 31, 2018

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 that there were various areas along the walls in the infant and toddler and preschool/school age programs where paint was chipping. These areas were within the reach of children. As a result, a chalk powder was exposed and the residue remained on fingers when touched. Licensing expressed concerns of children touching and ingesting the powder.

On February 1st, Licensing observed that the exposed chalk was covered in the infant program.
Corrective Action(s): Please ensure the facility is in good repair while children are in care.
Date to be Corrected: February 2, 2018

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: Licensing reviewed 4 staff files and observed that record of criminal record clearance letters (CRC) were missing for 2 staff and there was no evidence of previous CRC's. On January 31, 2018, the licensee contact stated that the CRC for one staff member was being processed and that the CRC for the other staff member was not yet processed. This is a repeat contravention as it was coded on the last routine inspection (IMAY-AHJNMW).

On February 1st, Licensing observed current record of CRC for one of the staff members. This CRC just needs to be shared.
Corrective Action(s): Please obtain, for each staff member, a record of their CRC prior to employment. Licensing is requesting a written response the staff with no evidence of CRC will continue working pending the CRC.
Date to be Corrected: February 1, 2018

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 reviewed 4 staff files and observed that 3 staff were missing record of their immunization status. This is a repeat contravention as it was coded on the last routine inspection (IMAY-AHJNMW).
Corrective Action(s): Please obtain, for each staff, a record of their immunization status prior to employment
Date to be Corrected: January 8, 2018

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: Licensing reviewed 4 staff files and observed that the criminal record check clearance letter (CRC) was not shared with the facility for one staff. Information from the previous place of employment was on the CRC.
Corrective Action(s): Please ensure all records required under section 19 (1) of the CCLR are current.
Date to be Corrected: January 8, 2018

CARE AND/OR SUPERVISION: 14030 - CCLR s.34(2)(b) - Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Observation: It was identified that a responsible adult worked as second staff in the toddler program in the morning of January 31, 2018. Licensing explained that the second staff in the IT programs need to have ECE or ECE Assistant (if the ECE is absent) qualifications. The licensee contact stated that the staffing schedule will be changed.
Corrective Action(s): Please ensure appropriate staffing as per Schedule E or section 37 of the CCLR if staff are absent.
Date to be Corrected: January 31, 2018


Comments

The following was discussed with the licensee contact on February 1, 2018:

Ways to capture evidence of completing character reference checks if only a list of names and phone numbers have been provided;
Information that can be included in a missing or wandering policy;
Information that can be included in interim care plans;
Requesting an exemption if the staff who sent documentation for certificate renewal do not receive certificates before expiration of valid certificate.

Licensing would like to thank the staff and licensee contact for their time and assistance.


Useful websites to consider:
I. Criminal Records Checks at https://justice.gov.bc.ca/eCRC/home.htm
II. ECE Registry for all education resources at www.mcf.gov.bc.ca/childcare/ece

The following resources were provided:
· Immunization Poster x5;
· Child Care Links- Checklist x3;
Reportable Incident form x4.

The report was reviewed with a staff member today.

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 02, 2018

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