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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KINE-CKBV5A

FACILITY NAME
CEFA South Delta
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
MLAO-AN5PJN
FACILITY ADDRESS
202 - 4890 Canoe Pass Way
FACILITY PHONE
(778) 322-3629
CITY
Tsawwassen
POSTAL CODE
V4M 0B1
MANAGER
Yat Lok Nian Chan

INSPECTION DATE
October 18, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
11:30 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care Assisted Living Act (CCALA) and 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: One classroom had a staff certificate posted who is no longer working at this facility. The replacement staff certificate was not posted in the facility although a copy was available to review. One classroom has 3 staff but only 2 certificates were posted.
Corrective Action(s): Ensure all educator or assistant staff certificates are posted in a prominent place in the facility.
Date to be Corrected: November 1, 2022

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: The change mats located in three of the infant/toddler washrooms are torn with the foam showing though. The change mats are no longer able to be sanitized adequately. (this is a repeat contravention)
Corrective Action(s): Ensure a healthy and safe environment is provided at all times
Date to be Corrected: October 19, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11020 - CCLR s.13(2) - A licensee must ensure that the community care facility and the furniture, equipment and fixtures within it are clean and in good repair while children are in attendance.
Observation: Walls in five out of six classroom had chipped paint and areas where the drywall was exposed at the child level. Nap rooms also had chipped paint and areas where the drywall was exposed. (This is a repeat contravention).
Corrective Action(s): Ensure the facility is in good repair.
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11200 - CCLR s.17 - A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child.
Observation: The following was observed:
1. All of the children's nap rooms have electrical outlets that have video surveillance cameras plugged into them and are accessible to children who may be sleeping in the room. The manager stated that staff supervise children through video surveillance while they are sleeping so this presents a possible hazard.
2. All washrooms were observed to have cleaners stored within reach of children (this is a repeat contravention) and some of the washrooms had diaper cream and sunscreen available at child level. (corrected during inspection)
Corrective Action(s): 1. Ensure the children do not have access to electrical plugs and outlets or provide direct adult supervision in the nap rooms until the outlets can be secured.
2. Ensure cleaners and creams are stored out of reach of children
Date to be Corrected: October 19, 2022

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: - A minimum of two verified character references were not obtained for one staff member.
- A minimum of three character references were not obtained for the manager
Corrective Action(s): Ensure staff files are complete
Date to be Corrected: November 1, 2022

POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(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: A review of six classrooms found that one classroom did not have all of the fire drills recorded for the year.
Corrective Action(s): Ensure records are kept current for each classroom.
Date to be Corrected: Ongoing

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: A review of ten files found that three files did not have immunization status identified.
Corrective Action(s): Ensure children's files are complete
Date to be Corrected: November 1, 2022

RECORDS AND REPORTING: 19260 - CCLR s.58(2)(b) - The licensee must (b) review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.
Observation: The care plan was not reviewed annually with the parent or any person requested to by the parent
Corrective Action(s): Review the care plan at least once per year with the parent of the child
Date to be Corrected: November 1, 2022


Comments

During this inspection, there were 67 children and 17 staff present. At this inspection, the above noted contraventions were identified.The Licensee will take action to bring the facility into compliance and provide a written response to the Licensing Officer by November 1 , 2022. The Licensing Officer will review the response.
The Licensing Officer met with the manager/licensee contact and discussed the following:
Immunization declaration for staff and children
Exemption/Temp Placement
Lead in the Water - resource provided via email
Request to measure of outside play space - to be determined at a later date

As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy was provided to the facility along with this report. The Risk Assessment includes any non-compliance identified during the routine inspection and a 3 year ‘historical’ review of the facility’s compliance and operation and is used to determine inspection frequency.
The contents of the inspection report were reviewed with the licensee prior to the inspection report being written off-site; therefore, no signature attached. A copy of this report will be emailed to the manager on October 18, 2022.
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 LicensingNo action required
Due Date
Nov 01, 2022

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