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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-B6VTBE

FACILITY NAME
St. Alban's The Martyr Day Care
SERVICE TYPES
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
3274013
FACILITY ADDRESS
7717 19th Ave
FACILITY PHONE
(604) 522-6228
CITY
Burnaby
POSTAL CODE
V3N 1E8
MANAGER
Pam Venketaya

INSPECTION DATE
November 26, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:30 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
23

Introduction

The Community Care Facilities Licensing officer (CCFL) conducted an unscheduled routine inspection of this community care facility (CCF) to assess compliance w/ the:
• Community Care & Assisted Living Act (CCALA)
• Child Care Licensing Regulation (CCLR)
• Director of Licensing Standard of Practice (DLSP)
- Active Play
- Safe Play Space

At the time of inspection, evidence for this facility inspection report (FIR) was based upon:
• CCFL's:
- observations
- review of the CCF's records
• information provided to CCFL by the manager

CCFL reviewed these 10 areas today:
• licensing • physical facility • staffing
• policies & procedures • care & supervision • hygiene & communicable disease control
• medication • nutrition & food services • program
• records & reporting

As part of this inspection, CCFL completed & provided a risk assessment tool, which includes:
• any noncompliance identified
• the CCF's compliance & operational history since 26/Nov/2015

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: 10050 - CCLR s.11(1) - A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation (CORRECTED DURING INSPECTION): The manager's name wasn't displayed conspicuously.
Corrective Action(s):
Date to be Corrected:

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: Employee:
- A requires a CRC share
- B lacked a CRC altogether
Corrective Action(s): Please apply for a:
- CRC share for Employee A
- CRC for Employee B (they can't be left alone w/ children or assist in the bathroom till their CRC arrives)
Date to be Corrected: 10/Dec/2018

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: Employee B lacked 3 character references.
Corrective Action(s): The licensee must ensure that 3 references are obtained & checked prior to hiring.
Date to be Corrected: 29/Nov/2018

STAFFING: 12060 - CCLR s.19(1)(c) - 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: (c) a record of the person's work history.
Observation: Employee B lacked their resume.
Corrective Action(s): The licensee must ensure that all requirements of § 19 are obtained prior to employees' 1st day of employment.
Date to be Corrected: 03/Dec/2018

STAFFING: 12070 - CCLR s.19(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Employee B lacked evidence of training & skills.
Corrective Action(s): The licensee must obtain evidence of Employee B's training & skills.
Date to be Corrected: 03/Dec/2018

STAFFING: 12090 - CCLR s.19(1)(f) - 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: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Employee A lacked their immunization status.
Corrective Action(s): The licensee must ensure all requirements of § 19 are obtained prior to employees' 1st day of employment.
Date to be Corrected: 03/Dec/2018

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 (CORRECTED DURING INSPECTION): The annual emergency plan practice that occured in 2018/10 wasn't documented.
Corrective Action(s):
Date to be Corrected:

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: CCFL reviewed 10 children's files & found that 1 child lacked their medical practitioner's name & #.
Corrective Action(s): The licensee must ensure that all reuqirements of § 57 are obtained prior to children's 1st day of care.
Date to be Corrected: 03/Dec/2018

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: A physical or digital photograph wasn't available for all children.
Corrective Action(s): The licensee must ensure a photograph is available for all children in the case of an emergency.
Date to be Corrected: 29/Nov/2018


Comments

The CCALA, CCLR, & DLSP set the minimum standards that must be met by all licensed CCFs to ensure the health & safety of all vulnerable individuals in care. The onus rests w/ the licensee to provide for the health & safety of all children in care @ all times.

Continuous, active supervision (§ 39 of the CCLR)
The licensee must ensure that:
• children are actively supervised @ all times by ≥ 1 responsible adult while maintaining the minimum employee to children ratio @ all times
• employees practice active supervision via a combination of close proximity & attention, watching, & listening, while being able to move through & see the entire space that children are in

Notification of illness or injury (§ 55 of the CCLR)
While a child is in care, the licensee must notify:
• a parent or emergency contact immediately after the child becomes ill, injured, or is (possibly) involved in a reportable incident (RI)
• CCFL ≤ 24 hours after a child is (possibly) involved in an RI
- this requirement can be fulfilled via email, phone, or fax
- in CCFL's absence, please report to the FHA Population & Public Health Central Call Centre (604.587.3936)
- please deliver the yellow copy of the completed RI form to FHA CCFL (#300 - 4946 Canada Way, Bby, BC V5G 4H7)

Safe drinking water (§ 48 of the CCLR)
Recent lead testing in many communities has shown higher concentrations in tap water than previously expected. CCFL discussed the importance of flushing pipes by running the cold water tap, as per the provided BC Govt Fact Sheet (CCLR, CCALA): "Lead in Drinking Water."

CCFL:
• reviewed this FIR w/ the manager prior to signing & printing
• thanks the manager & employees for their time & assistance today

Please visit http://www.fraserhealth.ca/childcare/ for:
• links to the CCALA, CCFL,& DLSP
• PHSA's free online course (Healthy Eating in the
Child Care Setting - Division of Responsibility model) • the temporary placement/retention application form
• the exemption application form
• additional resources

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 03, 2018

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