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

FACILITY NAME
1st Step Montessori Inc - Sunbury Hall
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
MLAO-A92NPK
FACILITY ADDRESS
10409 Dunlop Rd
FACILITY PHONE
(604) 417-3290
CITY
Delta
POSTAL CODE
V4C 2L1
MANAGER
Randeep Bal

INSPECTION DATE
January 26, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
08:45 AM
DEPARTURE
12:45 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: 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: The licence was not posted in a prominent place in the facility.
Corrective Action(s): Ensure the licence is displayed in a prominent place in the facility
Date to be Corrected: February 9, 2024

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: During inspection the following was observed:
-The windows on the second floor of the building have been replaced and now open up wide enough for a child to fit through. There are no restrictors on the windows and they present a severe fall hazard.
-The refrigerator's temperature was measured at 8 degrees and appeared to not be working. Food that was to be served to children was stored in this section of the fridge.
-A video monitor was plugged into the outlet next to a baby crib giving the child direct access to the plug going into the outlet.
- A 5 foot unsecured ladder is stored up against the wall in the children's washroom.
- Two fire extinguishers have been removed from the harness used to secure them to the wall and pose a hazard to children
- A stall door in the children's washroom downstairs has fallen off and is being stored up against the washroom stall wall and is unsecured.
-One set of Electrical plug covers were missing in the infant/toddler room (were replaced during inspection) and 2 sets in the nap room.
-The sanitization bottle is shared between the kitchen and washroom
-Nap mats are stacked together and are touching

Corrective Action(s): A corrective action must be submitted to licensing
Date to be Corrected: February 5, 2024

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: During the inspection licensing observed:
-The heavy metal door in the washroom stall in the downstairs area, had fallen off and struck the toilet and broke the lid. The manager reported that the door fell over the weekend while the children were not in care approx 2 weeks before inspection. The broken toilet back was covered with a piece of plastic that was taped down. The door was propped on it's side against the wall in the stall.
-The newly painted walls had chips and require repair in the downstairs infant toddler room and 30 months - school age rooms.
- toys for disposal were stored in the hallway
- items such as heater, air/fan unit, easel were stored in the nap room
- The heat register in the upstairs childcare room is not longer adhered to the floor.
Corrective Action(s): A corrective action plan must be submitted to licensing
Date to be Corrected: January 29, 2024

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: Medicated cream is stored in an unlocked cabinet in the washroom at child level. A tub of air freshener with an open top was stored on the counter in the washroom at child level
Corrective Action(s): Secure all medicated cream and air fresheners so that children do not have access
Date to be Corrected: January 26, 2024

POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: Some of the food supplies contained in the emergency kit had expired. Several of the fire extinguishers had signs on them that stated they had been inspected and failed inspection and required replacement.
Corrective Action(s): Ensure all supplies and equipment meant for responding to an emergency are in good working order and have not expired.
Date to be Corrected: February 9, 2024

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 records in the Infant/Toddler classroom found that fire and emergency drills had not been recorded since October of 2023
Corrective Action(s): Ensure all fire and emergency drills are recorded when practiced
Date to be Corrected:

CARE AND/OR SUPERVISION: 14030 - CCLR s.34(2)(b) - Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Observation (CORRECTED DURING INSPECTION): A review of daily attendance records and staff certificates revealed that since October, 2023 the infant toddler room has not had an Infant Toddler certified staff from 8am - 9AM each day.
Corrective Action(s): Ensure that the ratio of staff to children is not less that permitted in schedule E
Date to be Corrected: January 26, 2024


Comments

At today’s inspection there were 28 children and 7 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 Monday January 29, 2024. 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 licensee prior to the inspection report being written off-site (due to a computer problem); therefore, no signature attached. A copy of this report will be emailed to the manager on January 26, 2024.
The Licensing Officer met with the manager and discussed the following:
Record documentation of reference checks
Shared CRC

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
Jan 29, 2024

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