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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
ONIR-CJMQ63

FACILITY NAME
St. Francis de Sales Parish Before & After School Care
SERVICE TYPES
305 Group Child Care (School Age)
FACILITY LICENSE #
ACAK-8ZV22M
FACILITY ADDRESS
6656 Balmoral St
FACILITY PHONE
(604) 435-5311
CITY
Burnaby
POSTAL CODE
V5E 1J1
MANAGER
Maria Matrona Chondroyannos

INSPECTION DATE
September 23, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.75
ARRIVAL
02:45 PM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
5

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.

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: During the routine inspection the following were observed:
- manager's name was not on display in a prominent location
- facility license was not on display in a prominent location
Corrective Action(s): Please ensure that the manager's name as well as the facility's license are on display in a prominent location.
Date to be Corrected: October 21, 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: During the routine inspection 3 staff files were reviewed and 2 staff files had an RCMP CRC present. However, the CRC must be through the Criminal Record Check Review Program and not RCMP.
Corrective Action(s): Please ensure all staff files are complete.
Date to be Corrected: October 21, 2022

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: During the routine inspection 3 staff files were reviewed and two (2) staff files were missing a resume.
Corrective Action(s): Please ensure all staff files are complete.
Date to be Corrected: October 21, 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: During the routine inspection 3 staff files were reviewed and 3 staff files were missing an immunization record.
Corrective Action(s): Please ensure all staff files are complete.
Date to be Corrected: October 21, 2022

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: During the routine inspection it was noted that the facility did not have enough food to mitigate, respond and recover from any emergency.
Corrective Action(s): Please ensure you have enough food and water to prepare, mitigate, respond and recover from any emergency.
Date to be Corrected: October 21, 2022

POLICIES AND PROCEDURES: 13040 - CCLR s.56(1)(a) - A licensee must keep current records of each of the following: (a) written policies and procedures for the safe release of children.
Observation: During the routine inspection it was observed that a Safe Release of children policy was not available.
Corrective Action(s): Please ensure a Safe Release Policy is created and reflects the practices of the facility.
Date to be Corrected: October 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: During the routine inspection it was observed that an Active Play and Screen Time policy was not available. Documentation for Director of Licensing Standard of Practice (DOLSOP) link was provided to licensee via email.
Corrective Action(s): Please ensure that an Active Play and Screen Time policy is created and reflects the practice of the facility.
Date to be Corrected: October 21, 2022

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: During the routine inspection it was observed that on several days in September the daily attendance sheet was not completed.
Corrective Action(s): Please ensure that the daily attendance sheet accurately reflects the attendance of the children at the facility.
Date to be Corrected: October 21, 2022


Comments

At the inspection dated September 23, 2022 there were 5 children, 1 staff, 1 manager, and the principal of the school present. At this inspection the above noted contraventions were identified. Actions required by the licensee and actions required the LO included here. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.

The following education/recommendations were provided:
· Promoting Active Play in the program
· Active and continuous supervision was discussed with the staff and manager
· Maintaining and the use of log book was discussed with the manager
· A system for keeping the children's files updated and having all necessary items on file was discussed
· Reviewing Policies and procedures was discussed with the manager
· Amending the license discussion was had with the manager and the principal. The necessary paper work was sent to the principal and manager via email.
· Staff immunization (Fraser Health form) was emailed to manager
· Lead in the Water

The following resources were provided:
· Reportable Incident Bulletin
· Reportable incident forms

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

· This report has been written off site. No signature was needed. This report was discussed and emailed to the licensee.

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
Oct 21, 2022

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