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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
DCHG-AEFNGB

FACILITY NAME
Kingsway Christian Children's Centre
SERVICE TYPES
302 Group Day Care >30 mos
FACILITY LICENSE #
3279004
FACILITY ADDRESS
4061 Kingsway
FACILITY PHONE
(604) 437-3393
CITY
Burnaby
POSTAL CODE
V5H 1Y9
MANAGER
Marie Sanders

INSPECTION DATE
September 28, 2016
ADDITIONAL INSP. DATE (multi-day)
October 05, 2016
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
02:25 PM
DEPARTURE
05:00 PM
ARRIVAL
12:10 PM
DEPARTURE
01:00 PM
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) and the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 operation.

Visit the CCFL website http://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 # 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: 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: 5 staffs files were reviewed and they appeared organized except that two staff's reference checks were not in file.
Corrective Action(s): Please ensure that the facility has obtained at least two character references from each staff and kept them in file for review upon request.

Date to be Corrected: Oct 31, 2016

POLICIES AND PROCEDURES: 13050 - CCLR s.56(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Observation: Fire drill record sheets were reviewed. There has no record of fire drill since June 2016 and there has no record of emergency drill in the last few years.
The staff stated that the fire drills were done monthly and the emergency drills were done yearly, however, they have forgotten to record them.

Corrective Action(s): The facility must keep records of all fire drills and emergency drills.

Date to be Corrected: Oct 31, 2016

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: A polysporin was found in the first aid bag. Staff stated that they may apply polysporin to children for a cut. However, staff stated that they had not obtained a consent or authorization from parents before they applied the polysporin.
Polysporin is considered as a medication. The staff must obtain parents' authorization to administer the polysporin to children.

Corrective Action(s): Please do not use polysporin on children unless the facility has obtained parent's authorization.

Date to be Corrected: Sep 28, 2016


Comments

The inspection could not be completed on September 28 due to time constraint. Part of this report was written in office and delivered to the facility manager on Oct 5, 2016.

Two LIVE 5210 starter kits were provided and discussed.

In regards to the staff evaluation, the manager stated parts of the staff evaluations were done in January 2016. However, the manager has not completed them yet. As per Licensing's previous findings in year 2014, the facility policy stated that staff's performance should be evaluated every 1-2 years. However, this policy has not been implemented. The facility should follow their policy of formally evaluating each staff member on a regular basis and keep records of this in staff files. The manager has a plan to finish them by the end of the year. Thank you.



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
Oct 31, 2016

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