LICENSING: 10020 - CCLR s.10(2)(a) - Licensees must not make any structural change to a community care facility unless the licensee first (a) submits plans for the change to a medical health officer.
Observation: Licensing observed structural changes in the outdoor play space. A new deck has been installed to create an outdoor classroom. Additional changes will also be made in the coming weeks. The Licensee will need to submit a plan to licensing.
Corrective Action(s): Please ensure a plan is submitted to licensing for any structural changes to a community care facility.
Date to be Corrected: August 19, 2020
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: Licensing observed the following:
- Children's bedding is stored on their beds and left out in the nap area and sometimes stacked all together, posing a risk for bacteria and germs to spread.
- Bleach solution is made every 2 days. The manager could not confirm how often the solution was made as there is a specific staff responsible solely for cleaning.
- The manager could not confirm how often children's sleeping mats were cleaned. Due to covid mats need to be disinfected daily.
- The manager could not confirm how often children's toy's were cleaned. Due to covid toys need to be disinfected daily.
- There are expired topical creams in the first aid kits.
Corrective Action(s): Please ensure a healthy and safe environment is provided at all times.
Date to be Corrected: August 20, 2020
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: Licensing observed the following in the outdoor play area:
- The fence is showing signs of wear and beginning to sag in some areas. Due to the wet, marshy ground in the Queensborough area, this poses a hazard for the fence to fall over in some areas.
- Some of the outdoor toys are starting to show signs of wear and tear
Corrective Action(s): Please ensure the furniture, equipment and fixtures are clean and in good repair.
Date to be Corrected: August 19, 2020
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 selection of staff files were reviewed. Out of the 5 reviewed:
- 2 staff had no criminal record checks. The manager stated attempts have been made to complete this, additional fingerprinting is required for one staff member.
- 1 staff had a criminal record check addressed to another facility. This is noted to be a repeat contravention.
Corrective Action(s): Please ensure a valid cirminal record check has been obtained for all employees in a community care facility.
Date to be Corrected: August 19, 2020
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: A selection of staff files were reviewed. Out of the 5 reviewed 1 did not have any character references.
Corrective Action(s): This is noted to be a repeat contravention. Please ensure character references in respect of the employee is on file.
Date to be Corrected: August 19, 2020
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: A selection of staff files were reviewed. Out of the 5 reviewed 3 staff did not have a resume.
Corrective Action(s): This is noted to be a repeat contravention. Please ensure a record of employee's work history is on file.
Date to be Corrected: August 19, 2020
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: A selection of staff files were reviewed. Out of the 5 files reviewed 1 had an expired Early Childhood Educator Certificate. The manager will need to submit to Licensing a plan for the employee to continue work as part of ratio.
Corrective Action(s): Please ensure a valid ECE certificate is on file.
Date to be Corrected: August 19, 2020
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: A selection of staff files were reviewed. Out of the 5 reviewed 1 had no immunization status.
Corrective Action(s): This is noted to be a repeat contravention. Please ensure evidence that an employee has complied with the Province's immunization and tuberculosis control program is on file.
Date to be Corrected: August 19, 2020
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 licensee using a system established and maintained by the director of the early childhood educator registry,
Observation: A selection of staff files were reviewed. Out of the 5 reviewed 1 had an expired validation.
Corrective Action(s): Please ensure an employee that holds an educator or an assistant certificate has a valid verification completed by the director of the early childhood educator registry on file.
Date to be Corrected: August 19, 2020
STAFFING: 12190 - CCLR s.22(2)(b) - A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.
Observation: Licensing noted fire drills were only completed in January and February. The manager stated he believes a fire drill was completed but has not been recorded.
Corrective Action(s): Please ensure each employee practices implementing the fire drill system at least once each month.
Date to be Corrected: August 19, 2020
STAFFING: 12200 - CCLR s.22(2)(c) - A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.
Observation: Licensing noted the emergency plan was not completed for 2019. There was no record avaialble to review and the Manager could not recall if one was completed.
Corrective Action(s): This is noted to be a repeat contravention. Please ensure each employee practices implementing the emergency plan at least once each year.
Date to be Corrected: August 19, 2020
STAFFING: 12210 - CCLR s.23(1)(a) - A licensee must ensure that children have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: A selection of staff files were reviewed. Out of the 5 files reviewed:
- One staff has an expired first aid certificate
- One staff did not have any first aid certificate available to review
Corrective Action(s): Please ensure children at all times have immediate access to an employee who holds a valid first aid and CPR certificate.
Date to be Corrected: August 19, 2020
MEDICATION: 16030 - CCLR s.53(2)(a) - A licensee must ensure that a child's medication is not accessible to any child, except that a child may have access to his or her own medication if (a) the child's parent has instructed the licensee to permit this.
Observation: Licensing observed a child had their emergency medication in their backpack. The manager stated the parents forget to give the staff the emergency medication in the morning. There is no written permission from parents that allows the child to have access to their own medication. The emergency medication is also expired.
Corrective Action(s): Please ensure child's medication is not accessible to any child, except if a parent has instructed the licensee to permit.
Date to be Corrected: August 19, 2020
RECORDS AND REPORTING: 19070 - CCLR s.57(2)(a) - A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: A random selection of children's files were reviewed. Out of the 5 reviewed:
- 2 children did not have a care card number on file
- 2 children did not have an immunization status on file
Corrective Action(s): Please ensure a record showing the medical insurance plan and immunization status is on file.
Date to be Corrected: August 19, 2020
RECORDS AND REPORTING: 19080 - CCLR s.57(2)(b) - A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Observation: A random selection of children's files were reviewed. Out of the 5 reviewed all 5 did not have an enrollment date. The manager puts the academic school year as the enrolment date however, this isn't sufficient.
Corrective Action(s): Please ensure a record showing the date of enrolment in the facility is on file.
Date to be Corrected: August 19, 2020
RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure.
Observation: Licensing observed the sign in/out sheet did not indicate on some days whether a child was absent or present.
Corrective Action(s): Please ensure a record indicating for each day whether a child is absent, present and the time of arrival and departure.
Date to be Corrected: August 19, 2020
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: A random selection of children's files were reviewed. Out of the 5 reviewed:
- 2 children did not have a doctor on file
- 1 child did not have an emergency contact
Corrective Action(s): Please ensure a record indicating the name and telephone of a medical practioner and emergency contact is on file.
Date to be Corrected: August 19, 2020
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 random selection of children's files were reviewed. Out of the 5 reviewed 1 did not have a photo on file.
Corrective Action(s): Please ensure a photograph or digital image for each child is on file.
Date to be Corrected: August 19, 2020
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 random selection of children's files were reviewed. Out of the 5 reviewed:
- 1 child has a care plan on file that does not have current information. This care plan also does not have a date as to when the care plan was made.
- 1 child has no care plan. This child will be leaving the facility in 2 weeks.
Corrective Action(s): Please ensure a care plan is created in consultation with a parent of the child requiring extra support.
Date to be Corrected: August 19, 2020
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