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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
WBET-CGHRUB

FACILITY NAME
Captain Alpha Childcare
SERVICE TYPES
302 Group Child Care (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
JLEE-C99Q8X
FACILITY ADDRESS
4304 Parker St
FACILITY PHONE
(778) 888-8132
CITY
Burnaby
POSTAL CODE
V5C 3C5
MANAGER
Chai-Chen Chang

INSPECTION DATE
July 20, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
09:30 AM
DEPARTURE
11:30 AM
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), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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 name of the manager is not posted in the facility.
Corrective Action(s): Please ensure the name of the manager is posted in a prominent place.
Date to be Corrected: July 29, 2022

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: Two climbers are in the Group Child Care (30 months to school age) program yard. Although not anchored to the ground the climbers are located on a hard surface which will not reduce the risk of injury from falls. One climber does not have a 6 feet clearance around it.
Corrective Action(s): The Director of Licensing Standards of Practice Safe Play Spaces states a 6 feet clearance around equipment and the depth guidelines for loose fill material is a minimum of 6 inches for 5 foot high equipment. Please ensure that the outdoor play area is constructed in a way to mitigate the risk of harm to children.
Date to be Corrected: July 29, 2022

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: Files for five staff were reviewed. Criminal record checks for two staff had not been obtained through the CRRA Sharing program.
Corrective Action(s): A current criminal record must be available for all staff and if a criminal record check is from another facility or college it must be obtained through the Criminal Record Review Agency Sharing program.
Date to be Corrected: July 29, 2022

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: Files for five staff were reviewed. Proof of references being verified was not available in three files and one file had no references.
Corrective Action(s): Please ensure all staff files have references and proof of references being verified is available.
Date to be Corrected: July 29 2022

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: Files for five staff were reviewed. Immunization status was not available for one staff.
Corrective Action(s): Please ensure current immunization status is available for all staff.
Date to be Corrected: July 29, 2022

STAFFING: 12430 - CCLR s.56(1)(b) - A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements].
Observation: A staff file was not available for one staff person.
Corrective Action(s): A current staff file must be available for all persons working at the facility.
Date to be Corrected: July 21, 2022

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: A copy of the facility policies and procedures were not on site.
Corrective Action(s): Please ensure that a copy of the facility policies and procedures are available to all staff.
Date to be Corrected: July 22, 2022

CARE AND/OR SUPERVISION: 14020 - CCLR s.34(2)(a) - Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.
Observation (CORRECTED DURING INSPECTION): A child was does not attend kindergarten has been provided care in the Group Child Care (school age) program. Only children who attend school can be registered in this program. The manager said the school age program is a "summer camp" and that is why the child was registered there.
Corrective Action(s): Unless a temporary placement has been obtained from Licensing, children in the Group Child Care (school age) program must attend school. To address this contravention the manager said the child is now enrolled in the Group Child Care (30 months to school age) program.
Date to be Corrected:

MEDICATION: 16020 - CCLR s.53(1)(b) - If a licensee has agreed with a parent to give a child any medication prescribed by a medical practitioner or provided by the parent, the licensee and his or her employees must ensure that the medication is (b) readily accessible to employees.
Observation (CORRECTED DURING INSPECTION): Medication required in a care plan for a child in the Group Child Care (30 months to school age) program was located in the Group Child Care (school age) program and was not readily accessible to employees.
Corrective Action(s): The manager brought the medication into the Group Child Care (30 months to school age) program during this inspection.
Date to be Corrected:

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 reviewed time in/out sheets for the past 3 months. Time out was missing on multiple days. One child was not signed into the Group Child Care (school age) program today.
Corrective Action(s): Please ensure time and out is recorded daily for each child.
Date to be Corrected: July 21, 2022

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: Children's files were not at the facility. Although the manager said emergency cards for children were on site, two children did not have an emergency card. The manager said the Licensee had taken the children's file off site.
Corrective Action(s): Please ensure children's files are available for inspection.
Date to be Corrected: July 21, 2022


Comments

Summary of Inspection
At the inspection dated July 20, 2022 there were ten children and three staff present. 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. The Licensing Officer will review the response. As part of this routine inspection, a facility risk assessment tool is completed and a copy is provided. This report was reviewed with the manager and written off site. A copy of this report will be emailed to the manager and the Licensee.
The following were discussed with the manager:
The school age program must be in compliance with the legislation at all times regardless of what the Licensee calls the program or how long children are registered in the program.
Ensuring all perishable items in lunch boxes are stored in the fridge.
A copy of the Community Care Assisted Living Act and the Child Care Licensing Regulation must be available to staff (either on-line or a hard copy).
Although the flooring in the 3-5 program has been repaired twice it is beginning to warp again and could possibly pose a tripping hazard. It is recommended that a permanent solution to this issue be found.
If a child does not have a family doctor, the name of the clinic the family uses can be listed on the registration forms.
Ensuring the staffing qualification checklist is complete and current.
Contact the Licensing Officer if there are questions about the operation of the facility.
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 LicensingFollow-up Inspection Required
Due Date
Jul 29, 2022
Approximate Follow Up Date

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