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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Pinewood Leisure Centre
SERVICE TYPES
305 Group Child Care (School Age)
FACILITY LICENSE #
MLAO-AHWQ7T
FACILITY ADDRESS
11777 Pinewood Dr
FACILITY PHONE
(604) 952-3054
CITY
Delta
POSTAL CODE
V3V 2L5
MANAGER
Kelly Wilson

INSPECTION DATE
June 14, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.25
ARRIVAL
03:30 PM
DEPARTURE
04:40 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
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.
Visit the CCFL website at http://www.fraserhealth.ca/childcare for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)
If you have any questions regarding this report feel free to contact me at 604-507-5490 or at sharmel.yu@fraserhealth.ca

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: There is a staff person who is missing their staff file, therefore CRC clearance is unavailable. The Licensee has changed to having a letter indicating what files are contained at head office and some copies of the files available at the facility.
Corrective Action(s): Evidence of CRC completed through the Solicitor General must be complete
Date to be Corrected: June 28, 2018

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: Staff person is missing evidence of refence checks being completed
Corrective Action(s): Please ensure staff file is complete
Date to be Corrected: June 28, 2018

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: Staff person is missing their resume
Corrective Action(s): Please ensure staff file is complete
Date to be Corrected: June 28, 2018

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: There are several staff that are missing their information regarding their training skills
Corrective Action(s): Please ensure staff files are complete
Date to be Corrected: June 28, 2018

STAFFING: 12151 - CCLR s.19(5)(a) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (a) a criminal record check for the person.
Observation: There is a volunteer who evidence of CRC clearance being completed is unavailable.
Corrective Action(s): Please ensure CRC has been completed
Date to be Corrected: June 28, 2018

STAFFING: 12152 - CCLR s.19(5)(b) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (b) character references in respect of the person.
Observation: Evidence that character references has been conducted is unavailable for the volunteer
Corrective Action(s): Please ensure references has been verified.
Date to be Corrected: June 28, 2018

STAFFING: 12153 - CCLR s.19(5)(c) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs. .
Observation: Immunization status for the volunteer is unavalable.
Corrective Action(s): Please ensure files are complete
Date to be Corrected: June 28, 2018

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: There are children who are missing their medical doctor contact information
Corrective Action(s): Please ensure records are complete
Date to be Corrected: June 29, 2018

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: There is a child who requires a care plan, the information available, does not provide enough information such as what are the symptoms to be aware of, and course of action.
Corrective Action(s): Please ensure care plan is complete
Date to be Corrected: June 29, 2018


Comments

Active Play and Screen use Policies were to be included in the Trifold program information.
The children were engaged in theme and free play activity, evidence of outdoor play was observed.
Staff supported the children with positive assistance.
Please provide a written response to how the above coded violations have been addressed by June 28, 2018.
Please ensure that the Manager and Licensee contact is made aware of the report. The report was not reviewed with the staff person.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Jun 28, 2018

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