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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KMBH-CM5VEE

FACILITY NAME
Fraser Heights Out of School Care/Tiny Tots Day School Program
SERVICE TYPES
302 Group Child Care (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
0982603
FACILITY ADDRESS
15783 106th Ave
FACILITY PHONE
(604) 582-1335
CITY
Surrey
POSTAL CODE
V4N 1K5
MANAGER
Kelly Francilia

INSPECTION DATE
December 15, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.25
ARRIVAL
02:45 PM
DEPARTURE
04:00 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), the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSP).

Contraventions
Previous Inspection -
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 noted:
-Shelving unit stacked on top of one another can act as a topple hazard as the unit is not secured to the wall.
-Thermometer within the fridge does not appear to be working, facility is unable to tell if fridge is within the appropriate temperature (0-4 Degrees Celsius).
Corrective Action(s): Please ensure a healthy and safe environment.
Date to be Corrected: December 22, 2022

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: Some staff only have names of references noted but there is no notation to show when the references were called.
Corrective Action(s): In order to confirm that references have been checked, please provide date that references was contacted.
Date to be Corrected: December 22, 2022

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: Copies of any diplomas, certificates or other evidence of the person's training and skills were not obtained.
Corrective Action(s): One staff does not have proof of training and skills on site.
Date to be Corrected: Please ensure staff files are complete.

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: The following were noted:
-Last emergency drill was carried out in September 2021, more than 1 year ago. Discussion had with staff about ensuring that emergency drill is conducted yearly.
-Within the emergency supplies, some of the items have a best before date of 2021. The bin appears to have a musty scent.
-Fire extinguisher is due to be serviced.
Corrective Action(s): Please ensure facility is able to prepare, mitigate, respond and recover to an emergency.
Date to be Corrected: January 15, 2023

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: 6 children's files reviewed, one child was missing enrolment date
Corrective Action(s): Please ensure children's files are complete.
Date to be Corrected: December 22, 2022

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: 6 children's files reviewed, 2 children were missing Dr information.
Corrective Action(s): Please ensure children's files are complete.
Date to be Corrected: December 22, 2022


Comments

At the inspection dated December 15, 2022, there were 12 children and 2 staff present.
At this inspection, the above noted contraventions were identified . Please provide a written response to indicate how you will address the contraventions noted above on or before December 22, 2022
As part of this Routine Inspection a Facility Risk Assessment Tool was completed.

The following was discussed:
-Sanitizing of facility
-Ensuring staff checklist is updated

Findings reviewed with Manager/staff

Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).

Please contact me if you have any questions or concerns.

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 22, 2022

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