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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SSWT-CY8SJR

FACILITY NAME
Aldergrove Daycare Centre
SERVICE TYPES
302 Group Day Care >30 mos
305 Group Child Care (School Age)
FACILITY LICENSE #
0982420
FACILITY ADDRESS
26770 29th Ave
FACILITY PHONE
(604) 856-3724
CITY
Aldergrove
POSTAL CODE
V4W 3B8
MANAGER
Mary-Ellen Kobayashi

INSPECTION DATE
December 04, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.17
ARRIVAL
11:50 AM
DEPARTURE
02:00 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) and the Child Care Licensing Regulation (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
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: Criminal Record Check not obtained. This is a recurring item of non-compliance.
Corrective Action(s): Ensure to obtain a site specific criminal record check for each staff, prior to employment.
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: A minimum of two character references were not obtained for one employee. This is a recurring item of non-compliance.
Corrective Action(s): Ensukre to obtain character references for each employee, prior to employment.
Date to be Corrected:

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 record of the person's work history was not obtained for one or more employees. This is a recurring item of non-compliance.
Corrective Action(s): Ensure to obtain a record of work history for each staff prior to employment.
Date to be Corrected:

POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: Emergency Supplies are insufficient to implement the emergency plan
Corrective Action(s): Ensure to have sufficient food and water to mitigate, respond to and recover from any emergency.
Date to be Corrected:

POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Observation: The licensee explained that the last fire drill was in September 2023. The last recorded fire drill was in August 2023. This is an item of recurring non-compliance.
Corrective Action(s): Ensure to practice fire drills monthly and maintain a written record of each drill.
Date to be Corrected:

POLICIES AND PROCEDURES: 13060 - CCLR s.56(1)(d) - A licensee must keep current records of each of the following: (d) written policies and procedures that are intended to guide employees in the care and supervision of children.
Observation: The Licensee has not developed an Active Play Policy or a Screen Use Policy.
Corrective Action(s): Ensure to develop an Active Play Policy and a Screen Use Policy which is to be provided to the staff and the parents.
Date to be Corrected:

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: Group Child Care - Staff to Child ratio not maintained. (ECE/ASST/ASST). This is a recurring item of non compliance.
Corrective Action(s): You must ensure that staff are qualified as per CCLR Schedule E.
Date to be Corrected: December 8, 2023

CARE AND/OR SUPERVISION: 14230 - CCLR s.51(1)(b) - A licensee must (b) provide to employees and parents a written statement of the licensee's policy on behavioural guidance.
Observation: The licensee's policy on behavioral guidance is under the licensee's review and is not provided to parents.
Corrective Action(s): Ensure to provide the Licensee's policy on behavioral guidance to parents.
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 15030 - CCLR s.46(1) - A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
Observation: Licensing observed that, after hand washing, all of the children were sharing the same towel to dry their hands.
Corrective Action(s): Ensure to use single use towels for hand drying.
Date to be Corrected:

RECORDS AND REPORTING: 19050 - CCLR s.56(1)(f) - A licensee must keep current records of each of the following: (f) a log of minor accidents, illnesses and unexpected events involving children, that did not require medical attention and were not reportable incidents described in Schedule H.
Observation: A current log of minor accidents, illnesses and unexpected events involving children is not maintained.
Corrective Action(s): Ensure to maintain a current log of minor accidents, illnesses and unexpected events involving children.
Date to be Corrected:

RECORDS AND REPORTING: 19051 - CCLR s.56.1(2)(a) - A licensee must keep (a) a copy of the written statement, referred to in section 19 of the Act, that the licensee delivers to persons who prepay part of the cost of services
Observation: The Licensee does not have a written statement that the licensee delivers to persons who prepay part of the cost of services.
Corrective Action(s): Ensure to provide a written statement to persons who prepay part of the cost of services and keep a current record of each person to whom the written statement is delivered..
Date to be Corrected:


Comments

During this inspection, the above noted contraventions were identified. As part of this Routine inspection, a Facility Risk Assessment Tool was completed.
The information contained in the report was discussed with the Licensee and the report and risk assessment were written off-site. Licensing emailed a copy of the report and the risk assessment to the facility.
The following was discussed with the Licensee during the inspection:
- first aid supplies
- care plans
- healthy and safe environment
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 08, 2023

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