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
AFUN-BE7TXD

FACILITY NAME
Roots & Wings Montessori Heritage House
SERVICE TYPES
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
NNAL-8KLMH5
FACILITY ADDRESS
15250 54A Ave
FACILITY PHONE
(604) 574-5399
CITY
Surrey
POSTAL CODE
V3S 8R7
MANAGER
Chami Fernando

INSPECTION DATE
July 18, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
01:00 PM
DEPARTURE
04:15 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 (DOLSOP). All areas of the facility were inspected for compliance.

Contraventions
Previous Inspection -
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: Two educators working in the program during the inspection did not have their certificates posted in the facility.
Corrective Action(s): Ensure all qualified educators have their certificates posted in the facility.
Date to be Corrected: August 1, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11190 - CCLR s.16(4)(b) - A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.
Observation: The outdoor play area was reviewed during this inspection and the following items require attention:
- the ground surface has exposed tarp that could pose a tripping hazard to the children playing in the area
- the resilient surfacing at the bottom of the slide does not have enough depth to support the children using the equipment
- a storage bin has a broken lid with sharp edges assessable to the children playing in the area
Corrective Action(s): Ensure all outdoor play materials and equipment accessible to the children are safely constructed and free from hazards and in good repair.
Date to be Corrected: August 1, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11200 - CCLR s.17 - A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child.
Observation: The facility first aid kit has medicinal products stored within it to use in the event of a minor injury. LO discussed the requirement for parental permission to use these products. The manager relayed that she would remove the items form the kits.
Corrective Action(s): Ensure children do not have access to substances that may be hazardous to their health and safety.
Date to be Corrected: August 1, 2019

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 staff working in the facility had CRC's that were not specific to the facility. LO discussed the practice of using a sharing form with the Manager during the inspection.
Corrective Action(s): Ensure all staff have valid CRC's in place before working in the facility.
Date to be Corrected: August 1, 2019

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: One staff working in the program did not have evidence of immunization status in the staff file.
Corrective Action(s): Ensure all staff working in the program have complete files including immunization status.
Date to be Corrected: August 1, 2019

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 licensee using a system established and maintained by the director of the early childhood educator registry,
Observation: Five staff files were reviewed and two staff did not have validated certificates through the ECE BC Registry. One staff validation had expired. LO discussed with the manager the requirement for re-validation when certificates are renewed.
Corrective Action(s): Ensure all staff files are complete including validation through the ECE Registry.
Date to be Corrected: August 1, 2019

CARE AND/OR SUPERVISION: 14030 - CCLR s.34(2)(b) - Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Observation: The staff to child ratio was meet at the time of the inspection. Two additional staff working in the program however did not have valid certificates (one expired and one new certificate had not arrived from the registry yet). LO discussed the requirement for an exemption application to be submitted and approved prior to the staff working in the program. The facility administrator was on hand to discuss the process of exemption applications today.
Corrective Action(s): Ensure the staff to child ratio meets no less that permitted in Schedule E.
Date to be Corrected: August 1, 2019

MEDICATION: 16050 - CCLR s.53(3)(a) - A licensee must ensure that at all times an employee is available who is competent to either (a) administer a child's medication as instructed by the child's parent or required by the child's record or care plan.
Observation (CORRECTED DURING INSPECTION): A child with allergies and a care plan in place was not communicated to a staff working with the group of children. This staff was observed during the inspection working alone with this child. The Manager discussed the specific circumstances regarding the child's allergy and care plan during the inspection.
Corrective Action(s): Ensure all staff are aware of specific details of allergies and care plans.
Date to be Corrected:

NUTRITION AND FOOD SERVICES: 17020 - CCLR s.48(1)(b) - A licensee must (b) promote healthy eating and nutritional habits.
Observation: Food items are being stored in the facility fridge. A thermometer is not available to ensure the appropriate temperature of the items in the fridge.
Corrective Action(s): Ensure healthy practices are promoted.
Date to be Corrected: August 1, 2019

RECORDS AND REPORTING: 19070 - CCLR s.57(2)(a) - A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: Four children's files were reviewed and one child did not have a medical insurance plan number available.
Corrective Action(s): Ensure all children's files are complete including Care Card Numbers.
Date to be Corrected: July 19, 2019

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: The attendance records were reviewed. It was observed that the records were not accurate with the number of children recorded, some arrival time and departure times were missing, and additionally absent children were not recorded.
Corrective Action(s): Ensure accurate attendance records are maintained.
Date to be Corrected: July 19, 2019

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: Four children's files were reviewed and one file did not have a name and phone number for a doctor available.
Corrective Action(s): Ensure all children's files are complete including Dr's name and contact details.
Date to be Corrected: August 1, 2019


Comments

Summary of Inspection
On the inspection date of July 18, 2019 there were 12 children and 4 staff present. At this inspection the above noted contraventions were identified. Actions required by the licensee include a corrective action plan required to be submitted and actions required the LO include to review and monitor corrective action plan and a follow up inspection required. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.
The following education/recommendations were provided:
Promoting Active Play in the program
Temporary Placement procedure
Active Supervision
Lead in the Water

The following resources were provided:
Facility Inspection Checklist
Reportable Incident Bulletin
Reportable incident forms
Immunization Poster
Licensing Officer’s Business Card

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 LicensingFollow-up Inspection Required
Due Date
Aug 01, 2019
Approximate Follow Up Date

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