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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
DCAR-AUNQYW

FACILITY NAME
The Open Door
SERVICE TYPES
305 Out of School Care
303 Preschool
301 Group Day Care <36 mos
FACILITY LICENSE #
0701098
FACILITY ADDRESS
2390 McMillan Rd
FACILITY PHONE
(604) 859-8406
CITY
Abbotsford
POSTAL CODE
V2S 7R3
MANAGER
Jennifer St. Jean

INSPECTION DATE
January 03, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
09:45 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
119

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

Contraventions
Previous Inspection - Contraventions observed on FIR #DCAR-AGDR9Z have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
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: 2 staff require valid / current CRC clearance , application for 1 staff was completed with the results not yet received. an additional staff holds a CRC which is not site specific
Corrective Action(s): please ensure staff are fully screened including that the manager has obtained a CRC , please forward your response to include how you will address this contravention.
Date to be Corrected: Jan 5, 2018

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: It was observed that a fire drill was not documented to have taken place in Dec 2017 within the Preschool Program.
Corrective Action(s): please ensure fire drill system is implemented monthly in order to assist in safe evacuation/ knowledge of steps
Date to be Corrected: Jan 12, 2018

MEDICATION: 16080 - 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: Care plan in place for child requiring life saving medication , it is however observed that the medication had expired.
Corrective Action(s): please ensure medication is approved / current in order to carry out the instructions as detailed within the care plan.
Date to be Corrected: Jan 7, 2018

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: observed internal documentation of an incident which in review was met the definition as reportable.
Corrective Action(s): please ensure staff are familiar with reporting requirements , reviewed schedule H with manager during the inspection.
Date to be Corrected: Jan 12, 2018


Comments

Discussed time spent outside , staff actively attempting to utilize the on-site play area however with think ice this was determined unsafe therefore children participated in Active Play opportunities within the Gym. Staff were encouraged to observed the duration of time children were engaged in seated activities verses free play and facilitated gross motor / active games.
Discussed storage and systems for relocation of emergency supplies
The report was reviewed with both the facility manager and Licensee contact.

As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at http://www.fraserhealth.ca/childcare for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)
Should you have any questions pertaining to this report please feel free to contact me.
Licensing would like to thank yhe facility manager and staff for their time during today's inspection.
Licensing Officer
Community Care Facilities Licensing

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
Jan 17, 2018

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