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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-BGUVXT

FACILITY NAME
PALS Autism Society
SERVICE TYPES
305 Group Child Care (School Age)
FACILITY LICENSE #
MLAO-B9UT6Y
FACILITY ADDRESS
101 Third St
FACILITY PHONE
(604) 251-7257
CITY
New Westminster
POSTAL CODE
V3L 2P9
MANAGER
Ray Asuncion

INSPECTION DATE
October 11, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.25
ARRIVAL
03:45 PM
DEPARTURE
05:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
2

Introduction

All areas of the community care facility (CCF) were inspected for compliance during an unscheduled routine inspection to assess compliance w/ the:
• Community Care & Assisted Living Act (CCALA)
• Child Care Licensing Regulation (CCLR)
• relevant Director of Licensing Standards of Practice (DLSP)

Contraventions
Previous Inspection - Not Applicable
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 (CORRECTED DURING INSPECTION): The manager's name wasn't displayed conspicuously.
Corrective Action(s):
Date to be Corrected:

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: CCFL reviewed all employees' files. An employee lacked 2 character references in her file.
Corrective Action(s): All requirements of s. 19 (Character & skill requirements) must be obtained by employees' 1st day of employment.
Date to be Corrected: 18/Oct/2019

STAFFING: 12070 - CCLR s.19(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: CCFL reviewed all employees' files. There was no evidence of employees' training & skills.
Corrective Action(s): All requirements of s. 19 (Character & skill requirements) must be obtained by employees' 1st day of employment.
Date to be Corrected: 18/Oct/2019

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: CCFL reviewed all children's files. 1 lacked lacked his immunization status.
Corrective Action(s): All requirements of s. 57 (Records for each child) must be obtained by children's 1st day of care.
Date to be Corrected: 18/Oct/2019

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: CCFL reviewed all children's files. Start dates weren't documented for any children.
Corrective Action(s): All requirements of s. 57 (Records for each child) must be obtained by children's 1st day of care.
Date to be Corrected: 18/Oct/2019

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: There were 4 children signed in in the morning that were never signed out. 3 of these children weren't present in the afternoon upon CCFL's inspection.
Corrective Action(s): Children attending the GCC (SA) on a regular school day must be signed:
- in upon arrival to the CCF in the AM
- out upon arrival to school in the AM
- in upon arrival to the CCF in the PM
- out upon pickup in the PM
Date to be Corrected: 15/Oct/2019


Comments

Summary of FIR # CGEE-BGUVXT (11/Oct/2019)
• the manager & 2 employees were present
• the abovenoted 6 violations were identified, in which 1 violation was corrected in CCFL's presence, & corrective action for the other 5 violations includes obtaining:
- employee documentation
- children's files
• a Facility Risk Assessment Tool was completed & provided

Education, recommendations, & relevant resources provided
• continuous active supervision (FHA CCFL Child Safety Alert)
• notification of reportable incidents (FHA CCFL Child Care Bulletin: Incident Reporting In Child Care Facilities)
• lead in drinking water (BC Govt Fact Sheet (CCLR, CCALA): "Lead in Drinking Water")
• mandatory inspections to assess applications for temporary placements/retentions & exemptions
• promotion of active play

Other resource provided
• FHA CCFL Staff Qualifications/Documentation – Child Care

Please visit http://www.fraserhealth.ca/childcare/ for additional resources & links to the provincial legislation.

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
Oct 18, 2019

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