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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-C9KTAN

FACILITY NAME
PALS Autism Society
SERVICE TYPES
305 Group Child Care (School Age)
FACILITY LICENSE #
MLAO-B9UT6Y
FACILITY ADDRESS
101 Third St
FACILITY PHONE
(604) 251-7257
CITY
New Westminster
POSTAL CODE
V3L 2P9
MANAGER
Jasline Malhi

INSPECTION DATE
December 10, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1
ARRIVAL
11:00 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

All care categories were inspected during an unscheduled routine inspection to assess compliance w/:
• the Community Care & Assisted Living Act (CCALA)
• the Child Care Licensing Regulation (CCLR)
• relevant Director of Licensing Standards of Practices (DLSP)

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
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: *Repeat violation from FIR #CGEE-BGUVXT (11-Oct-2019) & FIR #CGEE-BRCMVF (08-Jul-2020)*
10/15 employees lacked ≥ 2 character references in their files.
Corrective Action(s): All requirements of s. 19(1) must be obtained by employees' 1st day of employment.
Date to be Corrected: 17/Dec/2021

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: *Repeat violation from FIR #CGEE-BGUVXT (11-Oct-2019) & FIR #CGEE-BRCMVF (08-Jul-2020)*
10/15 employees lacked evidence of their training & skills in their files.
Corrective Action(s): All requirements of s. 19(1) must be obtained by employees' 1st day of employment.
Date to be Corrected: 17/Dec/2021

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: 6/15 employees lacked their immunization status in their files.
Corrective Action(s): All requirements of s. 19(1) must be obtained by employees' 1st day of employment.
Date to be Corrected: 17/Dec/2021

STAFFING: 12190 - CCLR s.22(2)(b) - A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.
Observation: *Repeat violation from FIR #CGEE-BRCMVF (08-Jul-2020)*
A few fire drill practices were missed this year.
Corrective Action(s): Fire drills must be practiced monthly.
Date to be Corrected: 17/Dec/2021

STAFFING: 12210 - CCLR s.23(1)(a) - A licensee must ensure that children have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: There are times when there are no first aid/CPR certified employees onsite.
Corrective Action(s): There must be ≥ 1 first aid/CPR certified employee available to children @ all times.
Date to be Corrected: 07/Jan/2022

CARE AND/OR SUPERVISION: 14360 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: There are currently 5 youth/adults in care between age 13-21.
Corrective Action(s): Children can no longer attend the facility on their 13th birthday. FHA & the manager discussed ways to come into compliance.
Date to be Corrected: 17/Dec/2021

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 (CORRECTED DURING INSPECTION): *Repeat violation from FIR #CGEE-BGUVXT (11-Oct-2019)*
Today's & yesterday's attendance weren't documented.
Corrective Action(s):
Date to be Corrected:


Comments

Summary of FIR #CGEE-C9KTAN (10/Dec/2021)

7 violations were observed today, in which 1 violation was corrected today & corrective action for the remaining 6 violations includes:
• obtaining employee documentation
• practicing implementation of the monthly fire drill system
• caring for children within the age range of the program type

Licensees & employees play a key role in protecting children from, & minimizing the impact of infection & illness. CCFL discussed hand washing, cleaning, & physical distancing as per BCCDC's "Public Health Guidance for Child Care Settings" (http://www.bccdc.ca/Health-Info-Site/Documents/COVID_public_guidance/Guidance_Child_Care.pdf).

The inspection was reviewed w/ the manager; however, this report & the Facility Risk Assessment Tool were written @ the Burnaby Health Protection office & emailed to the manager on 10/Dec/2021.

Please visit https://www.fraserhealth.ca/childcare for resources & links to the provincial legislation.

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 17, 2021

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