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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CLAN-D3QU8D

FACILITY NAME
Deaf Children's Society of BC
SERVICE TYPES
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
3283133
FACILITY ADDRESS
4446 Watling St
FACILITY PHONE
(604) 430-5415
CITY
Burnaby
POSTAL CODE
V5J 5H3
MANAGER
Debra Moffatt

INSPECTION DATE
March 26, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:45 AM
DEPARTURE
12:45 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 Regulation (CCLR) and the 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
LICENSING: 10070 - CCLR s.11(4) - A licensee must display in a prominent place in the community care facility the certificate, or a copy of the certificate, of any educator or assistant employed to work in the community care facility.
Observation: One staff certificate was not posted in the facility
Corrective Action(s):
Date to be Corrected: April 2, 2024

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 a bottle of cleaning solution on the washroom on the floor. The label stated keep out of reach of children.
Corrective Action(s):
Date to be Corrected: March 26, 2024

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: Two of the staff records did not contain a Criminal record check
Corrective Action(s): Please ensure to apply for a criminal record check prior to the start of employment. Please ensure staff are not working without an additional staff present until this is completed.
Date to be Corrected: April 9, 2024

RECORDS AND REPORTING: 19030 - CCLR s.55(2)(a) - A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee.
Observation: Licensing observed the children's records. The Licensee did not notify the licensing officer within 24 hours that a child was involved in or may have been involved in a reportable incident as described in Schedule H as required.
Corrective Action(s): Please report reportable incidents to Licensing within 24 hours.
Date to be Corrected:

RECORDS AND REPORTING: 19190 - CCLR s.57(3)(a) - A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached.
Observation: The children's records were reviewed. Four children's records were missing consent to call a medical practitioner or ambulance in an emergency. This is a repeat contravention from inspection #CLAN-CQBPZ3 and #CLAN-BXTVP3
Corrective Action(s):
Date to be Corrected: April 2, 2024

RECORDS AND REPORTING: 19210 - CCLR s.58(1)(a) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (a) the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.
Observation: No care plan available for a child requiring extra support. The child started care in September 2023
Corrective Action(s): Please ensure a child's care plan is reviewed and onsite prior to the child starting in the program.
Date to be Corrected: April 2, 2024

RECORDS AND REPORTING: 19260 - CCLR s.58(2)(b) - The licensee must (b) review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Observation: Several care plans were observed from 2022. Care plans were not observed to be reviewed annually with the parent or any person requested to by the parent.
Corrective Action(s): Please ensure to have current documentation and current care plans located in one place in the facility.
Date to be Corrected: April 9, 2024

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: The following policies and procedures were not readily available for review during the inspection:
-Behavioural guidance policy
-Nutrition Policy
-Emergency evacuation policy
-Health and Illness Policy
-Medication Policy
-Active Play
-Screen Use
-Safe Release policy
-Communicable Disease Policy

The following documentation was missing from the staff records and a staff documentation checklist was not completed:
-Character references (4 staff records)
-Immunization status(4 staff records)
-Copies of diplomas and certificates or evidence of training and skills (3 staff records)
-Record of a person's work history (5 staff records)
-Certificate validation (2 staff records)

Corrective Action(s): Please ensure the documentation for policies and procedures and staff records is on site and available for review.
Date to be Corrected: April 2, 2024


Comments

At the inspection dated March 26, 2024 there were no children, 1 staff and the Manager was present. During this inspection the above noted contraventions were identified. Please correct the above noted contraventions by April 9, 2024 unless otherwise specified in the report. As part of the inspection the Facility Risk Assessment Tool is completed and a copy was provided to the Manager.

The following was discussed with the Manager:

-Reportable incident reporting
-Lead in the water prevention
-The outdoor play area plan for the facility
-Creating systems for records
-Utilizing approved and effective cleaning products for the classroom and equipment.
-Using a bound book for a minor incident log

This report was reviewed with the Manager during the inspection. The report was written off-site. The report was reviewed with the Manager by phone prior to completion. A copy of these documents were sent to the Manager. An unscheduled A follow up inspection will be completed at a later date to observe the children in care. If you have any questions regarding this report please contact me.

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
Apr 09, 2024
Approximate Follow Up Date

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