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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CLAN-BHHPGV

FACILITY NAME
Maywood Neighbourhood Care
SERVICE TYPES
305 Group Child Care (School Age)
FACILITY LICENSE #
3283094
FACILITY ADDRESS
4567 Imperial St
FACILITY PHONE
(604) 431-0484
CITY
Burnaby
POSTAL CODE
V5J 1B7
MANAGER
Mary-Anne Sanders

INSPECTION DATE
September 24, 2019
ADDITIONAL INSP. DATE (multi-day)
November 01, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
03:10 PM
DEPARTURE
05:00 PM
ARRIVAL
02:45 PM
DEPARTURE
05:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSP). All areas of the facility were inspected for compliance.

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: 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: Licensing observed the following inside the facility:

-Three electrical outlets were exposed.

Corrective Action(s): Please ensure a healthy and safe environment is provided at all times.
Date to be Corrected: November 1, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11080 - CCLR s.15(1)(a) - A licensee must supply equipment, furniture and supplies that are (a) of sturdy and safe construction, easy to clean and free from hazards.
Observation: During the inspection a rusty tap and sharp and rusty drain was observed in the wasroom. This could contain a potential health hazard.
Corrective Action(s): Please ensure the facility is free from hazards.
Date to be Corrected: November 22, 2019

STAFFING: 12151 - CCLR s.19(5)(a) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (a) a criminal record check for the person.
Observation: During the inspection a volunteer was present at the facility. No volunteer record was availble for review at the facility. A criminal record check (CRC) was not present. In discussion with the Manager she stated that all of the information has been completed and the information is at the head office.
Corrective Action(s): Please ensure the volunteer records are complete and available for review.
Date to be Corrected: November 4, 2019

STAFFING: 12152 - CCLR s.19(5)(b) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (b) character references in respect of the person.
Observation: During the inspection a volunteer was present at the facility. No volunteer record was availble for review at the facility. References were not available for review. In discussion with the Manager she stated that all of the information has been completed and the information is at the head office.
Corrective Action(s): Please ensure the volunteer records are availble for review.
Date to be Corrected: November 4, 2019

STAFFING: 12153 - CCLR s.19(5)(c) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: During the inspection a volunteer was present at the facility. No volunteer record was availble for review at the facility. An immunization record was not present. In discussion with the Manager she stated that all of the information has been completed and the information is at the head office.
Corrective Action(s): Please ensure the volunteer records are complete and available for review.
Date to be Corrected: November 4, 2019

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: Licensing observed the record of fire drills. In discussion with the Manager she stated that a fire drill was not practiced for August. This is a repeat contravention from inspection # ABEY-B7LW4T.
Corrective Action(s): Please ensure to practice implementing the fire drill on a monthly basis
Date to be Corrected: November 15, 2019

STAFFING: 12200 - CCLR s.22(2)(c) - A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.
Observation: In discussion with the Manager she stated that the emergency plan has not been completed for this year or last year
Corrective Action(s): Please ensure the emergency plan is completed on an annual basis.
Date to be Corrected: November 15, 2019

STAFFING: 12430 - CCLR s.56(1)(b) - A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements].
Observation: During the inspection two employee records were reviewed for the three employees working at the facility. The record for the third employee was not present. In discussion with the Manager she stated that the employees record is complete but it is in transition from another facility. The health and safety risk to children in care was discussed.
Corrective Action(s): Please ensure staff records are complete and available for review on site.
Date to be Corrected: November 4, 2019

CARE AND/OR SUPERVISION: 14060 - CCLR s.39(1) - A licensee must ensure that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.
Observation: During the inspection licensing observed the following:

1. The children were lining up to go outside. One of the children left the facility without the group and headed to the playground. The Manager called to the child to return and then closed the door. The child was left unsupervised until the group had gathered and headed outside.

2. One of the children was moving back and forth from the intermediate room to the primary room

3. Three children entered the facility to use the washroom. One of the children went into the primary room and started to particiapate in the art activity. I spoke with the child about the importance of staying with the group and how the child needed to let the outside teacher know if they were inside. The three children left the facility to rejoin the group outside.

The Manager and I discussed these concerns and the importance of providing active supervision to the children and having a discussion with the children in care.

This is a repeat contravention inspections: #ABEY-B7LW4T and #CLAN-B9EVS4

Corrective Action(s): Please ensure children are adequately supervised at all times
Date to be Corrected: November 1, 2019

CARE AND/OR SUPERVISION: 14270 - CCLR s.52(1)(b) - A licensee must ensure that a child, while under the care or supervision of the licensee, is not subjected to any of the following: (b) confinement or physical restraint by an employee, except as authorized in a child care's plan if the care plan includes instructions respecting behavioural guidance.
Observation: During the inspection licensing observed inappropriate guidance strategies being used at the facility. The emergency restraint used twice by staff was not outlined in a child's care plan. Licensing reviewed this observation with the Manager and the staff and discussed alternative guidance strategies.
Corrective Action(s): Please ensure an emergency restraint is only used when outlined in a child's care plan.
Date to be Corrected: September 24, 2019

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: Ten children's records were reviewed. Five children were missing the date of enrollment.
Corrective Action(s): Please ensure children's records are complete.
Date to be Corrected: November 15, 2019

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: Ten children's records were reviewed. One children's record was missing an emergency contact name and number.
Corrective Action(s): Please ensure children's files are complete.
Date to be Corrected: November 15, 2019

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: Two care plans for providing medication during an emergency were reviewed. The date the care plans were reviewed was written as August 2017.
Corrective Action(s): Please ensure care plans are reviewed on an annual basis to comply with the legislation.
Date to be Corrected: November 15, 2019


Comments

At the inspection dated September 24, 2019 and November 1, 2019 there were 25 children and 4 staff present and 16 children and 3 staff and 1 volunteer were present. At this inspection the above noted contraventions were were identified. Please ensure you send a written response to Licensing by November 14, 2019 addressing how you have corrected the noted contraventions. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.

The following education/recommendations were provided:
· Promoting Active Play in the program
· Active Supervision
· Lead in the Water
· The emergency supplies did not seem to be able to be transported in an easy manner. Licensing made recommendations for easy transport.

The following resources were provided:
· Reportable Incident Bulletin

This report was reviewed with the Manager prior to signing.

Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).

If you have any questions regarding this report feel free to contact me.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Due Date
Nov 15, 2019
Approximate Follow Up Date

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