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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MPEE-BS2QV9

FACILITY NAME
Brilliant Kids Montessori Childcare Centre
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
MLAO-AZUUYR
FACILITY ADDRESS
11706 96th Ave
FACILITY PHONE
(604) 498-2128
CITY
Delta
POSTAL CODE
V4C 3W7
MANAGER
Yung Jung Chang

INSPECTION DATE
July 31, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:15 AM
DEPARTURE
12:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

A scheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSOP).
This inspection was conducted during the Covid-19 pandemic. Covid-19 prevention strategies were noted and discussed.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 10050 - CCLR s.11(1) - A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation: Licensing observed a facility manager's name posted on the wall. This facility manager is no longer the manager of the facility.
Corrective Action(s): Please ensure the name of the current manager is displayed in a prominent place in the community care facility.
Date to be Corrected: August 7, 2020

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 the following inside the facility:
- Bleach solution bottles are not labeled. A staff member stated the solution is made every 2-3 days. Bleach solution is no longer as concentrated and strong to disinfect surfaces and needs to be replaced every 24 hours.
- Childrens bibs are hung to dry really close to each other and the bibs are touching posing a risk for bacteria and germs to be spread easier.
- The fridge temperature was 5 degrees celcius.

Licensing observed the following in the outdoor play area:
- Little tikes slides and climbers in the outdoor play area have insufficient clearance around the equipment. (CORRECTED DURING INSPECTION)
- There is a large ladder stored in the 3-5 outdoor play area posing as a risk to the children
- There is a wire running across the outdoor play area and connected along the climber posing as a risk of electrocution for the children. The same wire is dangling off on one end posing as a risk for strangulation. (NEEDS IMMEDIATE ATTENTION)
- There are large rubber road ramps stored in the 3-5 outdoor play area
- There is a hose stored in the 3-5 outdoor play area posing a tripping hazard
- There are large wooden signs stored in the outdoor play area
Corrective Action(s): Please ensure a healthy and safe environment is provided at all times.
Date to be Corrected: August 7, 2020

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 2 tricycles in the 3-5 outdoor play area. 1 tricycle has several 'chewing' marks probably from an animal all over the tricyle. The other tricycle has rust along the handle bars.
Corrective Action(s): Please ensure furniture, equipment and fixtures are clean and in good repair.
Date to be Corrected: August 7, 2020

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11090 - CCLR s.15(1)(b) - A licensee must supply equipment, furniture and supplies that are (b) located so as not to block or hamper an exit in the case of fire or other emergency.
Observation (CORRECTED DURING INSPECTION): Licensing observed children's ride on toys stored in front of an emergency exit.
Corrective Action(s): This is noted to be a repeat contravention.the case of fire or other emergency.
Date to be Corrected: August 7, 2020

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 (CORRECTED DURING INSPECTION): Licensing observed several cleaning products stored in a children's bathroom that was unsecured. Cleaning products were also stored underneath an unsecured bathroom sink in the infant/toddler room
Corrective Action(s): Please ensure children do not have access to any object or substance that may be hazardous to the health or safety of a child.
Date to be Corrected: July 31, 2020

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: A selection of staff files were reviewed. Out of the 7 files reviewed 1 contained a criminal record check which was not site specific, another criminal record check was not available for review.
Corrective Action(s): Please ensure a current and valid criminal record check for employees in a community care facility is on file.
Date to be Corrected: August 7, 2020

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: A selection of staff files were reviewed. Out of the 7 files reviewed:
- There was no indication whether the staff references were checked for one staff member
- There was no references available for a second staff member
- There were only 2 references available for a third staff member
Corrective Action(s): Please ensure character references in respect of the employee in a community care facility is on file.
Date to be Corrected: August 7, 2020

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 licensee using a system established and maintained by the director of the early childhood educator registry,
Observation: A selection of staff files were reviewed. Out of the 7 files reviewed, 2 certificates contained no Validation.
Corrective Action(s): Please ensure a certificate is verified using a system established and maintained by the director of the early childhood educator registry.
Date to be Corrected: August 7, 2020

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: A selection of staff files were reviewed. Out of the 7 files reviewed 1 contained an expired criminal record check.
Corrective Action(s): Please ensure current records required under section 19(1) are on file.
Date to be Corrected: August 7, 2020

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: A random selection of children's files were reviewed. Out of the 8 reviewed, 1 contained no immunization status.
Corrective Action(s): Please ensure a record showing a child's immunization status is on file.
Date to be Corrected: August 7, 2020

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: A random selection of children's files were reviewed. Out of the 8 reviewed, 1 contained no enrollment date.
Corrective Action(s): Please ensure a record showing the date of enrollment is on file.
Date to be Corrected: August 7, 2020

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: A random selection of children's files were reviewed. Out of the 8 files reviewed, 3 contained no doctor's information. Another file contained no emergency contact.
Corrective Action(s): Please ensure a record showing the name and telephone number of a medical practioner and emergency contact is on file.
Date to be Corrected: August 7, 2020


Comments

At the inspection dated July 31, 2020 there were 10 children and 3 adults present.
Due to Covid-19 no signatures were obtained for this report. The report was written at the CCFL office and emailed to the Manager.

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.

The following discussions were had:
- Licensing reviewed the minor incident log. A discussion was had with a staff about what would be considered a minor incident and to ensure when documenting to include the five W's (who, what, when, where, why, how).

The following resources were provided:
- Covid-19 resource package for child care facilities
- Staff qualifications/documentation
- Child care links- children's records
- Child care links- My Checklist
Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).
If you have any questions regarding this report feel free to contact your Licensing Officer.

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
Aug 07, 2020
Approximate Follow Up Date
31 Aug, 2020

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