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

FACILITY NAME
Fraser Montessori Daycare
SERVICE TYPES
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
ACAK-8KZURW
FACILITY ADDRESS
1408 5th Ave
FACILITY PHONE
(604) 522-1586
CITY
New Westminster
POSTAL CODE
V3M 1Z5
MANAGER
Edith Ziolkiewicz

INSPECTION DATE
November 12, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
10:15 AM
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 and Assisted Living Act (CCALA), the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSP). All areas of the facility were inspected for compliance.

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
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: The following was observed inside the facility:
- There is a power bar placed on top of a shelf in the three to five program that was accessible to the children.
- There was no papertowel available in the School Age program children's bathroom. (CORRECTED DURING INSPECTION)

The following was observed in the outdoor play area:
- There is a wood board leaning against the fence with nails sticking out of it.
- There is a wood panel falling off the patio posing a risk to the children if it were to fall.
Corrective Action(s): Please ensure a healthy and safe environment is provided at all times.
Date to be Corrected: November 19, 2019

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: The following were observed inside the facility:
- Two adult chairs in the School Age program were ripped up and falling apart.

The following were observed in the outdoor play area:
- There are two large screws portruding out on the slide located on the climbing structure that poses a risk to the children.
Corrective Action(s): Please ensure the furniture, equipment and fixtures are clean and in good repair.
Date to be Corrected: November 19, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11230 - CCLR s.47 - A licensee must ensure that any heated water accessible to children is heated to no more than 49° Celsius.
Observation: The hot water temperature was measured in three out of seven sinks. All three sinks had a temperature reading between 51.7 degrees celsius and 52.6 degrees celsius.
Corrective Action(s): Please ensure any heated water accessible to children is heated to no more than 49 degrees celsius. At the time of inspection the licensee turned off the hot water in the bathrooms.
Date to be Corrected: November 15, 2019

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 four staff files reviewed, one of the files contained a share form however there was no current criminal record check (CRC) available.
Corrective Action(s): This is noted to be a repeated non-compliance. Please ensure a valid CRC is on file.
Date to be Corrected: November 19, 2019

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: A selection of staff files were reviewed. Out of the four staff files reviewed, one of the files did not contain a resume.
Corrective Action(s): This is noted to be a repeated non-compliance. Please ensure a record of the person's work history is on file.
Date to be Corrected: November 19, 2019

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 four staff files reviewed, three of the files did not have a validation from the Early Childhood Educator Registry.
Corrective Action(s): This is noted to be a repeated non-compliance. Please ensure any staff with an educator or assistant certificate, must be verified using a system established and maintained by the director of the early childhood educator registry.
Date to be Corrected: November 19, 2019

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: There is no indication a fire drill has been implemented.
Corrective Action(s): This is noted to be a repeated non compliance. Please implement the fire drill system at least once a month.
Date to be Corrected: November 19, 2019

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: There is no indication of an emergency plan conducted within the year.
Corrective Action(s): Please implement an emergency plan at least once each year.
Date to be Corrected: November 19, 2019

MEDICATION: 16050 - CCLR s.53(3)(a) - A licensee must ensure that at all times an employee is available who is competent to either (a) administer a child's medication as instructed by the child's parent or required by the child's record or care plan.
Observation: Licensing observed a care plan posted on the wall in the School Age program. Upon discussion with the staff, the staff mentioned they were not aware of where the Epi-pen for the child was located as well as did not know how to administer it.
Corrective Action(s): Please ensure that at all times an employee is available who is competent to administer a child's medication required by the child's record or care plan.
Date to be Corrected: November 13, 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: A random selection of children's files were reviewed. Out of the ten files reviewed, three files did not have a care card number.
Corrective Action(s): Please ensure a medical insurance plan number is on file for each child.
Date to be Corrected: November 19, 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: A random selection of children's files were reviewed. Out of the ten files reviewed, two files did not contain an enrollment date.
Corrective Action(s): Please ensure the date of enrolment is on file for each child.
Date to be Corrected: November 19, 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: The sign in/out sheet indicated on several days some children were not signed out.
Corrective Action(s): This is noted to be a repeated non compliance. Please ensure the sign in and out sheet accurately reflects for each child when they are absent, present and the time of arrival and departure.
Date to be Corrected: November 12, 2019

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 ten files reviewed, two files did not contain a doctors name or phone number.
Corrective Action(s): This is noted to be a repeated non-compliance. Please ensure a name and telephone number of a medical practioner is on file.
Date to be Corrected: November 19, 2019

RECORDS AND REPORTING: 19160 - CCLR s.57(2)(i) - A licensee must keep, for each child, a record showing the following information: (i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency.
Observation: A random selection of children's files were reviewed. Out of the ten files reviewed, five files did not contain a child's photo.
Corrective Action(s): Please ensure a photoraph or digital image for each child is kept on file.
Date to be Corrected: November 19, 2019

RECORDS AND REPORTING: 19220 - CCLR s.58(1)(b) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (b) the courses of action recommended by health care professionals to address the needs of the child requiring extra support.
Observation: A random selection of children's files were reviewed. Out of the ten files reviewed, two children's files indicated that the children required a care plan. There was no care plan in place.
Corrective Action(s): This is noted to be a repeated non-compliance. Please ensure for each child requiring extra support, a current care plan is on file.
Date to be Corrected: November 15, 2019

RECORDS AND REPORTING: 19320 - CCLR s.59(a) - In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58.
Observation: Licensing noted eighteen children in attendance but only fifteen children's files present. It was also noted one staff file was missing and unable to review.
Corrective Action(s): This is noted to be a repeated non-compliance. Please ensure the records referred to in sections 56 to 58 are kept in a single place at the facility.
Date to be Corrected: November 15, 2019


Comments

At the inspection dated November 12, 2019 there were 30 children and 5 adults present. At this inspection the above noted contraventions were identified.
Action required by the licensee includes providing a written response by November 19, 2019.
Actions required by licensing include review the written response and due to the nature of the contraventions a follow-up will be conducted.
Licensing reviewed the contraventions with the licensee in advance. Licensing officer completed the inspection at the CCFL Office and delivered at a later date. Review and delivery of the report was arranged with the Licensee.
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 provided:
- Licensing observed in the three to five and school age program a lack of programming. A discussion was had with the manager regarding providing more materials and equipment for each of the programs.
- A discussion was had with the manager in regards to looking over all staff and children's files and ensuring all information is current.
- A discussion was had with the manager regarding ensuring when providing paper towel to the children in the bathroom, it is best practice to ensure the paper towel is on a paper towel spool or dispenser to prevent cross-contamination when grabbing a paper towel. The children currently rip the paper towel off the roll.
- A discussion was had with the manager about going through the Policies & Procedures and ensuring they are relevant to the current practice.
The following resources were provided and reviewed:
- Child Care Incident Reporting in Child Care Facilities- April 2019
- Child Safety Alert
- Child Care Links- Your Checklist
- Child Care Links- Children's Records
- Child Care Links- Care & Supervision- Care plans
- CCFL Registration Form for Child Care
- Facility Staffing Plan
- Staff Qualifications/ Documentation
- Registration Form for Child Care
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. A business card was provided.

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
Nov 19, 2019
Approximate Follow Up Date
29 Nov, 2019

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