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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CLAN-B4XQTF

FACILITY NAME
Bright Star Montessori School Inc
SERVICE TYPES
302 Group Day Care >30 mos
FACILITY LICENSE #
NGIL-6LBU5P
FACILITY ADDRESS
7591 Gray Ave
FACILITY PHONE
(604) 790-3503
CITY
Burnaby
POSTAL CODE
V5J 3Z4
MANAGER
Florina Nitu

INSPECTION DATE
September 25, 2018
ADDITIONAL INSP. DATE (multi-day)
September 26, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
09:45 AM
DEPARTURE
12:15 PM
ARRIVAL
10:45 AM
DEPARTURE
12:15 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
48

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at http://www.fraserhealth.ca/childcare for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)
If you have any questions regarding this report feel free to contact me at christine.lawson@fraserhealth.ca or 604-918-7658

Contraventions
Previous Inspection - Contraventions observed on FIR ##GSIU-AL7PQC have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 10060 - CCLR s.11(3) - When advertising or otherwise offering services to the public, a licensee must identify the care program being offered.
Observation: Licensing observed the program being provided is advertised as a preschool on the facility website althought the community care facility license care type is listed as Group Daycare 30 months to school age. In discussion with the Manager, the Manager stated that Bright Star Montessori is offering a preschool program. The Manager stated she will change the program name from preschool to group daycare on the website. In addition the Manager stated she will communicate this change in the program to the parents.
Corrective Action(s): Please ensure the program being offered and advertised is consistant with the care program that is listed on the community care facilities license.
Date to be Corrected: October 9, 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: Licensing observed 4 staff members were missing one or two references. In discussion with the Manager she stated she uses check marks after the reference name after the individuals have been contacted.
Corrective Action(s): Please ensure staff files are complete. Please ensure more infomation such as the date the reference was checked and information on the result of the reference are documented.
Date to be Corrected: October 9, 2018

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: Licensing observed all of the children's files. Medical practitioner and emergency contact information was missing from 4 files.
Corrective Action(s): Please ensure children's files are complete.
Date to be Corrected: October 9, 2018

RECORDS AND REPORTING: 19320 - CCLR s.59(a) - In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58.
Observation: Licensing was informed by a staff member that she was hired as an extra support worker to work with one child. In conversation with the Manager, the Manager stated the child was supported by a community social service agency and the worker had the care plan for the child off site. The Manager stated she will be in contact with the community social service agency to obtain a copy of the child's care plan.
Corrective Action(s): Please ensure a care plan for a child requiring extra support is on site at the facility
Date to be Corrected: October 9, 2018


Comments

Licensing measured the temperature of the fridge in one of the rooms. The children's lunches are placed in the fridge and the program provides snacks to the children. The temperature was 4.8 degrees Celsius. Licensing recommends the fridge temperature be set to between 0 and 4 degrees Celsius to ensure safe food storage practices. Licensing observed one of the children's names was missing from an emergency allergy plan that was posted. Licensing recommends the children's name be added to the emergency allergy plan to ensure there is an extra layer of safety. This may help in the situation where a substitute staff member is working in place of a regular staff member. This was corrected during the inspection. Licensing will send the Manager a copy of the Director of Licensing Standards of Practice Safe Place Space.

During this inspection the following was discussed with the Manager,

-their supervision process/active supervision.
-flushing of the water daily to ensure that there is no lead in the water
-when reporting any reportable incidents to get in direct contact with a Licensing Officer. If your Licensing Officer is unavailable then please call the Duty Line at (604) 587-3936.

Thank you for your time. This inspection was reviewed with the Manager prior to signing.
Please feel free to contact licensing if any concerns or questions arise. A business card was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Oct 09, 2018

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