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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
LPEN-C3SSK5

FACILITY NAME
CEFA Walnut Grove
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
DMIL-9U4N44
FACILITY ADDRESS
100 - 19950 88th Ave East
FACILITY PHONE
(604) 881-2332
CITY
Langley
POSTAL CODE
V1M 0A5
MANAGER
Jennifer Chaloner

INSPECTION DATE
June 07, 2021
ADDITIONAL INSP. DATE (multi-day)
June 08, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.75
ARRIVAL
11:15 AM
DEPARTURE
02:00 PM
ARRIVAL
10:00 AM
DEPARTURE
12:00 PM
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 care categories 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: 1 early childhood educator certificate was not posted.
Corrective Action(s): Ensure that each early childhood educator certificate is posted.
Date to be Corrected: 9-June-2021

STAFFING: 12220 - CCLR s.23(1)(b) - A licensee must ensure that children have at all times immediate access to an employee who (b) is knowledgeable respecting each child's medical condition, if any.
Observation: In one classroom all teachers, where a child had care plan present, were not familiar with the care plan.
Corrective Action(s): Ensure that the child has an employee who is knowledgeable respecting each child's medical condition.
Date to be Corrected: 9-June-2021

CARE AND/OR SUPERVISION: 14020 - CCLR s.34(2)(a) - Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.
Observation: It was observed that an infant toddler classroom with a maximum capacity of 12 had 13 children in care.
It was also observed that 11 of 13 children in an infant toddler program were over the age of 36 months.
Corrective Action(s): Ensure that the maximum capacity of the classroom is not exceeded.
Ensure that children are grouped according to schedule E.
Date to be Corrected: 9-June-2021

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: Two early childhood educators were scheduled to work on an infant toddler program with more than 8 children.
Corrective Action(s): Ensure that the ratio of employees to children attending a community care facility is no less than permitted in Schedule E.
Date to be Corrected: 9-June-2021

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: The facility has a staffing exemption in place. During the inspection it was observed that the facility is not following the staffing plan put forward in the application form.
Corrective Action(s): Ensure that any changes to the exemption form is submitted to and approved by the Licensing Officer prior to implementing it.
Date to be Corrected: 9-June-2021

HYGIENE AND COMMUNICABLE DISEASE: 15030 - CCLR s.46(1) - A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
Observation: It was observed in 3 of 9 classrooms were using towels to dry children's hands and they are not washed after each use. A discussion was had to ensure to use single use towels.
In one classroom a carpet was rolled up and located beside the toilet. There is concern that it may be exposed to urine and feces.
Corrective Action(s): Ensure that children are using single use towels.
Ensure that equipment is stored in appropriate and hygienic places.
Date to be Corrected: 9-June-2021

MEDICATION: 16020 - CCLR s.53(1)(b) - If a licensee has agreed with a parent to give a child any medication prescribed by a medical practitioner or provided by the parent, the licensee and his or her employees must ensure that the medication is (b) readily accessible to employees.
Observation: 3 children requiring medication did not have any accessible to employees.
Corrective Action(s): Ensure that any medication agreed with to give to a child is readily accessible to employees.
Date to be Corrected: 9-June-2021

MEDICATION: 16040 - CCLR s.53(2)(b) - A licensee must ensure that a child's medication is not accessible to any child, except that a child may have access to his or her own medication if (b) the nature of the child's medication is such that, without immediate access to the medication by the child, the child's health will be significantly at risk.
Observation: 4 of 9 children classrooms had children's medications accessible to children in the first aid bag.
Corrective Action(s): Ensure that medications are not accessible to children.
Date to be Corrected: 9-June-2021

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: 5 reportable incidents were not reported to the Licensing Officer.
Corrective Action(s): Ensure that Licensing is informed within 24 hours if a child has been involved in or may have been involved in a reportable incident.
Date to be Corrected: 9-June-2021

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: 1 of 30 children records reviewed did not contain a medical insurance plan number.
Corrective Action(s): Ensure that each child's records contain a medical insurance plan number.
Date to be Corrected: 9-June-2021

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: 1 of 30 children's record reviewed did not contain a medical practitioner name and contact information.
Corrective Action(s): Ensure that children's records contain a medical practitioner name and contact information.
Date to be Corrected: 22-June-2021

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: 1 of 9 employee files did not have a current criminal record check on file. The Licensee contact showed the criminal record check from an email.
Corrective Action(s): Ensure that all records are kept in a single location in the facility.
Date to be Corrected: 9-June-2021


Comments

Summary of Inspection
At the inspection dated June 7, 2021 and June 8, 2021 there were 94 children, 24 staff, and 2 practicum students present. At this inspection the above noted contraventions were identified. The Manager will take action to bring the facility into compliance and provide a written response to the Licensing Officer. The Licensing Officer will review the response. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.
The following education/recommendations were provided:
· Effective communications with Manager and Staff
· Temporary Placements/ retentions
· Active Supervision
· Non-reportable incident log
· Storage spaces and accessibility of emergency equipment.
· Ensuring allergy documentation is accurate and consistent when being presented to staff.

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
Jun 22, 2021
Approximate Follow Up Date

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