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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KINE-CLTVP3
FACILITY NAME
Pinewood Leisure Centre		SERVICE TYPES
305 Group Child Care (School Age)
303 Preschool (30 months to school age)
FACILITY LICENSE #
MLAO-AHWQ7T
FACILITY ADDRESS
11777 Pinewood Dr		FACILITY PHONE
(604) 952-3054
CITY
Delta		POSTAL CODE
V3V 2L5		MANAGER
Kelly Wilson
INSPECTION DATE
December 02, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
11:00 AM		DEPARTURE
01:00 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
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: A review of 4 staff files found that 2 files did not have verification of a current criminal record check on file.
Corrective Action(s): Ensure all staff files are complete
Date to be Corrected: December 19, 2022

STAFFING: 12150 - CCLR s.19(4)(b) - A licensee must not employ a person in a community care facility as (b) a responsible adult unless the person has the qualifications required under Division 2 [Employee Qualifications].
Observation: A review of staff files found that 2 staff have not completed a course or combination of courses of at least 20 hours duration in child development, guidance, health and safety or nutrition.
Corrective Action(s): Ensure all staff working in Responsible Adult positions have the necessary training and qualifications
Date to be Corrected: December 19, 2022

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 review of 6 children's files found that several of the children attending the School Age program did not have a record with a photo or digital image of the child.
Corrective Action(s): Ensure children 's files are complete
Date to be Corrected: December 19, 2022

RECORDS AND REPORTING: 19250 - CCLR s.58(2)(a) - The licensee must (a) develop the care plan in consultation with a parent of the child requiring extra support and any person requested by the parent.
Observation: A child with an allergy did not have a care plan developed.
Corrective Action(s): Ensure all children that require a care plan have one developed
Date to be Corrected: December 19, 2022
Comments

At today’s inspection there were 16 children and 2 staff present. Licensing conducted a walk through of the entire facility.
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 December 19, 2022. The Licensing Officer will review the response.
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 Manager over the phone 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 December 5 , 2022.
The Licensing Officer discussed with the manager the following:
Emergency cards - resource emailed to manager
Care Plans - resource emailed to manager
Staff Files
Children's files

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
Dec 19, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.