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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JCHE-AG7PUK

FACILITY NAME
Xtreme Performing Arts/Xplor Fine Arts Preschool
SERVICE TYPES
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
TBIU-ACNTPU
FACILITY ADDRESS
#11 & #12 - 34100 South Fraser Way
FACILITY PHONE
(778) 808-8827
CITY
Abbotsford
POSTAL CODE
V2S 2C6
MANAGER
Linda Merrick

INSPECTION DATE
November 30, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.25
ARRIVAL
10:00 AM
DEPARTURE
11:15 AM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled Routine Inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DLSOP). 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 the inspection.
The following areas were reviewed:

· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

As part of this 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 www.fraserhealth.ca/health-info/health-topics/child-care for:
· Additional resources, and
· Links to the Legislation (CCALA and CCLR)

Contraventions
Previous Inspection - Contraventions observed on FIR #JCHE-ADAT6V have been corrected.
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: 11010 - CCLR s.13(1) - A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.
Observation: There are boxes stored on top of the cubby system in the main entry room
Corrective Action(s): Please remove or secure these boxes to prevent possible injury from falling objects
Date to be Corrected: December 14, 2016

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: One staff had a CRC that was not site specific and the manager was unable to locate a CRC for another staff, the manager indicated that she does have site specific CRC's for both these staff but was unable to locate this documentation
Corrective Action(s): These two staff cannot be utilized until the manager locates their CRC's and ensures that the CRC's are on site
Date to be Corrected:

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: One staff had no proof of references checked
Corrective Action(s): Please ensure that there is a system in place that clearly indicates that references have been checked, please secure proof that this staff has had their references checked
Date to be Corrected: December 14, 2016

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: There is no records of ECE licence verification on site
Corrective Action(s): Please access the ECE Registry site and verify all ECE/ECEA licences and print off and retain verification documentation
Date to be Corrected: December 14, 2016

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: The manager was unable to locate any fire drill records for either the preschool or the school age program
Corrective Action(s): Fire drills for both service types must be completed and recorded every month
Date to be Corrected: December 14, 2016

PROGRAM: 18060 - CCLR s.44(3)(4)(5) - A licensee, other than a licensee providing a care program described as Occasional Child Care, must provide each child with daily outdoor play periods unless weather conditions would make it unreasonable to do so. (4) Despite subsection (1), a licensee who provides a care program described as Occasional Child Care need not provide a program of outdoor activities.
(5) Despite subsection (3), that subsection applies to a licensee who provides a care program described as Child-minding only if the program provides care for 3.5 hours or more each day.
Observation: The facility has an approved "away from facility playground plan" as there is no attached outdoor play area. This exemption still requires both service types to provide outdoor play each day at the approved away playground area detailed in the away from facility plan. The manager stated that they are not going daily to this approved outdoor play area
Corrective Action(s): Both programs must include daily outdoor play at the approved away from facility site
Date to be Corrected: Decemeber 14, 2016

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: At least one OOSC child was missing a care card number
Corrective Action(s): Please review all preschool and OOSC care children's files and ensure all required documentation is secured
Date to be Corrected: December 14, 2016

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: Today's sign in sheet did not have a record of departure times of children who attended the OOSC program this moring before school
Corrective Action(s): Please ensure departure times are recorded every day
Date to be Corrected: November 30, 2016

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: At least one child's records did not include a doctor's name and/or contact number
Corrective Action(s): Please review all children's files and ensure all required documentation is secured
Date to be Corrected: December 14, 2016

RECORDS AND REPORTING: 19160 - CCLR s.57(2)(i) - A licensee must keep, for each child, a record showing the following information: (i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency.
Observation: There were no photos available for the out of school care program, the manager stated that she has photos of the preschool children on her phone
Corrective Action(s): Please ensure photos of all children registered are secured and easily available for inspection
Date to be Corrected: December 14, 2016

RECORDS AND REPORTING: 19370 - DLSOP Safe Play Space (maintenance of equipment [b3]) - [bullet 3] Keep a log of all inspections, maintenance and repairs.
Observation: Once the daily use of the away from facility outdoor play begins, a record must be kept showing that the away from facility play area was inspected for any safety hazards
Corrective Action(s): A system must be developed to record daily inspections of outdoor play areas
Date to be Corrected: December 14, 2016


Comments

Live 5-2-1-0 resources were left for the manager. The requirement to have completed policies and procedures for an Active Play and screen time policy by September 2017 was discussed with the manager. The printer did not work at this inspection, licensing went through the report with the manager and will fax a copy of the report later today. Please feel free to contact me if you have any questions.

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 14, 2016

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