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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NSAO-CYAV7Z

FACILITY NAME
Fraser Montessori Daycare
SERVICE TYPES
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
ACAK-8KZURW
FACILITY ADDRESS
1408 5th Ave
FACILITY PHONE
(604) 522-1586
CITY
New Westminster
POSTAL CODE
V3M 1Z5
MANAGER
Edith Ziolkiewicz

INSPECTION DATE
December 07, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:00 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 and Assisted Living Act (CCALA), the Child care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DoLSoP). All care categories were inspected for compliance.

This is the second full routine due to the facility's medium risk rating.

Contraventions
Previous Inspection -
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: 11090 - CCLR s.15(1)(b) - A licensee must supply equipment, furniture and supplies that are (b) located so as not to block or hamper an exit in the case of fire or other emergency.
Observation: Toy structure on wheels blocking one of the emergency exits. Licensing and staff discussed storing this structure elsewhere in order to ensure a clear pathway to the exit.
Corrective Action(s): Please ensure emergency exits are not blocked.
Date to be Corrected: December 8, 2023

STAFFING: 12140 - CCLR s.19(4)(a) - A licensee must not employ a person in a community care facility as (a) an educator or an assistant unless the person holds a certificate issued under Division 2 [Employee Qualifications], which must be verified by the system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: 1/5 staff with a validation on file for a previous certification.
Corrective Action(s): Please ensure validations on file are current.
Date to be Corrected: December 14, 2023

POLICIES AND PROCEDURES: 13060 - CCLR s.56(1)(d) - A licensee must keep current records of each of the following: (d) written policies and procedures that are intended to guide employees in the care and supervision of children.
Observation: Reportable Incident policy currently named "Accidents" policy needs more detail and clarification. Licensing emailed the Reportable Incident bulletin to the Manager as a reference regarding what should be included in the policy.
Corrective Action(s): Please rename this policy to relfect "Reportable Incident". Please add in more detail as outlined in the RI bulletin.
Date to be Corrected: December 21, 2023

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: 2/7 children with parents as Emergency Contacts. 1 of the children's last day is tomorrow (Dec. 8, 2023). Licensing explained to the staff and Manager that the Emergency Contact must be an individual that is not the parent.
Corrective Action(s): Please obtain an Emergency Contact that is not the parent for the 1 child.
Date to be Corrected: December 14, 2023

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: 2/7 children missing a photo.
Corrective Action(s): Please ensure photos are obtained for these 2 children.
Date to be Corrected: December 14, 2023

RECORDS AND REPORTING: 19210 - CCLR s.58(1)(a) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (a) the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.
Observation: Care plan was not available for a child requiring emergency medication. The child's last day is tomorrow (December 8, 2023). Please submit a response to Licensing outlining how the facility will ensure that all children requiring emergency medication will have a care plan in place.
Corrective Action(s): Please ensure a care plan is in place for all children requiring emergency medication.
Date to be Corrected: December 21, 2023


Comments

At today’s inspection, there were 26 children, 4 staff, and 1 support worker. The Manager arrived part way through the inspection.


At this inspection, the above noted contraventions were identified and the Licensee is required to submit a compliance plan by the date below.

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 following was discussed:
-Program and designated spaces for each program
-Field Trip policy and consent forms available
-Transportation Policy and consent forms available for school drop-off and pick-up; revise form to indicate both school bus and car
-Emergency evacuation procedure
-System for replenishing food items in earthquake kits
-Clearly indicating each program on the separate attendance sheets
-Use of logbook
-Hand washing practices
-Diapering and toileting routine
-Storage of cleaning supplies
-Storage and laundering of nap time items
-Daily outdoor schedule and safety check
-Policies and procedures are a fluid document that can be revised. Any revisions must be shared with families.
-Copies of emergency consent cards in first aid kits
-Licensing Duty line: #604 587 3936 for emergencies if area Licensing Officer can’t be contacted.
-Regular review of BCCDC website for COVID-19 updates (see link below)

The following resources were provided:
-RI bulletin
-Medication Administration Form
-Asthma and Anaphylaxis care plan templates

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

Further websites:
Criminal Records Checks at:
www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
Appetite to Play at: https://www.appetitetoplay.com
Healthlink BC at: https://www.healthlinkbc.ca/services-and-resources/healthlinkbc-files
BCCDC for Covid-19 information: http://www.bccdc.ca/health-info/diseases-conditions/covid-19

The contents of this inspection report were reviewed with the Manager before being written off-site [time spent writing: 0.50]. A copy of the report was provided by mail.
If you have any questions, please contact your Licensing Officer.

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 21, 2023

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