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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KINE-CLF2LY

FACILITY NAME
Lil' Saints Preschool at Sacred Heart
SERVICE TYPES
303 Preschool (30 months to school age)
FACILITY LICENSE #
PNEL-8CVM6T
FACILITY ADDRESS
3900 Arthur Dr
FACILITY PHONE
(604) 551-0827
CITY
Delta
POSTAL CODE
V4K 3N5
MANAGER
Mylene Lock

INSPECTION DATE
November 21, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.5
ARRIVAL
11:00 AM
DEPARTURE
12:30 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 Assisted Living Act (CCALA) and the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DoLSoP). All care categories were inspected for compliance.

Contraventions
Previous Inspection - Contraventions observed on FIR #KINE-C9HR7X have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 12090 - CCLR s.19(1)(f) - 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: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: A sample of 3 files were reviewed and one file was missing immunization status
Corrective Action(s): Ensure files are complete
Date to be Corrected: December 5, 2022

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 system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: A review of 3 staff files found that one ECE certificate did not have proof of validation on file
Corrective Action(s): Ensure files are complete
Date to be Corrected: December 5, 2022

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: A review of 2 months of daily attendance records found that on 6 days some children did not have the time of departure indicated on the attendance record
Corrective Action(s): Ensure daily attendance records are complete
Date to be Corrected: Ongoing


Comments

At today’s inspection there were 23 children and 4 staff present. Licensing conducted a walk through of the entire facility.
At this inspection the above noted contraventions were identified. The Licensee will take action to bring the facility into compliance and provide a written response to the Licensing Officer by December 5 , 2022. The Licensing Officer will review the response.
As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy was provided to the facility along with this report. The Risk Assessment includes any non-compliance identified during the routine inspection and a 3 year ‘historical’ review of the facility’s compliance and operation and is used to determine inspection frequency.
The contents of the inspection report were reviewed with the licensee prior to the inspection report being written off-site; therefore, no signature attached. A copy of this report will be emailed to the manager on November 22, 2022.
The Licensing Officer met with the manager and discussed the following:
Licence Amendment process
Maintenance

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

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