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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-BG5RFF

FACILITY NAME
Beyond Care
SERVICE TYPES
302 Group Child Care (30 months to school age)
310 Multi-Age Child Care
FACILITY LICENSE #
3283113
FACILITY ADDRESS
8350 11th Ave
FACILITY PHONE
(604) 521-8748
CITY
Burnaby
POSTAL CODE
V3N 2P4
MANAGER
Khairunessa (Nessa) Karim Ahmed

INSPECTION DATE
September 18, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
10:30 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
11

Introduction

All areas of the community care facility (CCF) were inspected by Community Care Facilities Licensing (CCFL) for compliance during an unscheduled routine inspection to assess compliance w/ the:
• Community Care & Assisted Living Act (CCALA)
• Child Care Licensing Regulation (CCLR)
• relevant Director of Licensing Standards of Practice (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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11160 - CCLR s.16(3)(a) - A licensee must ensure that the entire outdoor play area is (a) enclosed in a manner that is suitable for the age and development of children, and will ensure that children are free of harm.
Observation: There's no barrier to prevent children from accessing the stairs from the outdoor play area to the CCF. CCFL observed employees physically preventing younger children from accessing these stairs.
Corrective Action(s): Please ensure these stairs are made inaccessible to children during outdoor play time.
Date to be Corrected: 23/Sep/2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11220 - CCLR s.23(2) - A licensee must have first aid kits that are readily accessible to all employees, including while care is provided off the community care facility premises.
Observation: An employee went to pick up school age children & didn't take the 1st aid kit.
Corrective Action(s): The 1st aid kit must be taken when children are taken or picked up offsite.
Date to be Corrected: Immediately

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: An employee lacked 1 character reference.
Corrective Action(s): All requirements of s. 19 must be obtained by employees' 1st day of employment.
Date to be Corrected: 23/Sep/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: 2 employees' ECE or ECEA certificates haven't been validated w/ the ECE Registry.
Corrective Action(s): Employees' ECE or ECEA certificates must be validated upon hire & again upon renewal.
Date to be Corrected: 23/Sep/2019

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: 1) Both licensed program types were playing together in the outdoor play space.

2) All 5 children present in the MACC program today were < 36 months old.
Corrective Action(s): 1) Children of different care types must not be blended together inside the CCF or in the outdoor play space. The only exception is the 1st ½ hour of the day & the last ½ hour of the day. During these times, children of different care types may be mixed if there are ≤ 8 children present. Of these 8 children, only ≤ 3 children are < 36 months old.

2) The manager was unaware that 1 MACC child who will be 36 months old next week may join the GCC (30m - SA) program immediately. All children currently enrolled in the GCC (30m - SA) are > 36 months old. The manager applied for a temporary placement for one child who is almost 30 months to move from the MACC to the GCC (30m - SA).
Date to be Corrected: Immediately

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: There was 1 ECE & 1 ECEA caring for 11 children (5 MACC & 6 GCC (30m - SA)).
Corrective Action(s): The correct employee to children ratio is as follows:
- MACC: 1 ECE : 8 children
- GCC (30m - SA): 1 ECE : 8 children / 1 ECE & 1 ECEA : 9-16 children
Date to be Corrected: 2019/09/19

RECORDS AND REPORTING: 19080 - CCLR s.57(2)(b) - A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Observation: CCFL reviewed all children's files & found that 1 lacked her enrolment date.
Corrective Action(s): Children's enrolment dates must be documented.
Date to be Corrected: 23/Sep/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: A school age child's attendance wasn't signed out upon transfer of care from the CCF to her school.
Corrective Action(s): School age children's attendance must be documented accurately:
- signed in upon arrival to the CCF
- signed out upon transfer of care from CCF to school
- signed in upon transfer of care from school to CCF
- signed out upon departure from the CCF
Date to be Corrected: Immediately

RECORDS AND REPORTING: 19180 - CCLR s.57(2)(k) - A licensee must keep, for each child, a record showing the following information: (k) the date on which the child stops attending the community care facility.
Observation: Several children's files didn't show their last day of care.
Corrective Action(s): Children's last day of care must be documented.
Date to be Corrected: 25/Sep/2019

RECORDS AND REPORTING: 19190 - CCLR s.57(3)(a) - A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached.
Observation: An employee went to pick up school age children & didn't take children's files or emergency consent cards.
Corrective Action(s): Children's emergency consent cards or files must be taken when children are taken or picked up offsite.
Date to be Corrected: Immediately


Comments

Summary of FIR #CGEE-BG5RFF (18/Sep/2019):
• the manager & an employee were present today
• the abovenoted 10 violations were observed today, in which corrective action includes:
- obtaining employee documentation
- obtaining children documentation
- ensuring each group has no more children than that permitted in Schedule E of the CCLR
- ensuring the minimum employee to children ratios are met @ all times
- ensuring children don't have access to the stairs that lead down to the CCF from the outdoor play space
• a Facility Risk Assessment Tool was completed & provided

Please visit http://www.fraserhealth.ca/childcare/ for additional 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
Sep 25, 2019

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