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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KINE-CYGMU6

FACILITY NAME
Lil' Saints Preschool at Sacred Heart
SERVICE TYPES
303 Preschool (30 months to school age)
FACILITY LICENSE #
PNEL-8CVM6T
FACILITY ADDRESS
3900 Arthur Dr
FACILITY PHONE
(604) 551-0827
CITY
Delta
POSTAL CODE
V4K 3N5
MANAGER
Mylene Lock

INSPECTION DATE
December 12, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.75
ARRIVAL
12:00 PM
DEPARTURE
01:45 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 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: 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: During inspection of the hallway of the facility, it was found that a large piece of the floor had chipped away from wear and tear and now presents a tripping hazard for children. Further down the hallway, in front of the washrooms, there is a portion of the floor that has worn down and the sub floor is now showing.
Corrective Action(s): Ensure the facility is in good repair and there is a maintenance plan in place.
Date to be Corrected: Plan for repair or replacement submitted by December 29, 2023

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: Four Staff files were reviewed and one file did not contain a record of the person's work history or resume.
Corrective Action(s): Ensure staff files are complete
Date to be Corrected: December 29, 2023

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: A review of 4 staff files found that one file did not contain the immunization status
Corrective Action(s): Ensure staff files are complete
Date to be Corrected: December 29, 2023

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 system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: Four staff files were reviewed and it was found that three certificates of staff had not been verified by the ECE registry.
Corrective Action(s): Manager must put a system in place to ensure staff certificates are verified through the ECE registry when they have been renewed every 5 years or when new staff are hired.
Date to be Corrected: December 29, 2023


Comments

At today’s inspection there were 18 children and 3 staff present. Licensing conducted a walk through of the entire facility.
At this inspection the above noted contraventions were identified. The Licensee will take action to bring the facility into compliance and provide a written response to the Licensing Officer by December 29, 2023. The Licensing Officer will review the response.
As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy was provided to the facility along with this report. The Risk Assessment includes any non-compliance identified during the routine inspection and a 3 year ‘historical’ review of the facility’s compliance and operation and is used to determine inspection frequency.
The contents of the inspection report were reviewed with the Manager onsite. A copy of this report will be emailed to the manager on December 13, 2023.
The Licensing Officer met with the manager and discussed the following:
Amendment to the licence
Anaphylaxis plans and resources for staff

Resource link provided:

www.foodallergycanada.ca

www.allergyaware.ca

Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR)

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
Dec 29, 2023

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