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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CLAN-CE6NX2

FACILITY NAME
Marlbrough Neighbourhood Care
SERVICE TYPES
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
NGIL-BUNQC6
FACILITY ADDRESS
5151 Sanders St
FACILITY PHONE
(604) 431-0400
CITY
Burnaby
POSTAL CODE
V5H 1T1
MANAGER
Scott Burgess

INSPECTION DATE
May 02, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
02:30 PM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

A 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 (DLSP). All areas of the facility were inspected for compliance with the exception of the outdoor play area as this is maintained by the Burnaby School Board.

Contraventions
Previous Inspection - Not Applicable
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: 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:
-missing plug covers
-loose cords under the overhead projector
-an ice pack missing from the first aid kit
-a large TV was on a rolling cart. The TV was not anchored to the cart.
Corrective Action(s): Please ensure a healthy and safe environment is provided at all times
Date to be Corrected: May 9, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11200 - CCLR s.17 - A licensee must ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child.
Observation: Licensing observed a bottle of bleach under the sink in the classroom. This was corrected during the inspection.
Corrective Action(s): Please ensure children do not have access to any objects or substances that are harmful to their health and safety.
Date to be Corrected: May 2, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11230 - CCLR s.47 - A licensee must ensure that any heated water accessible to children is heated to no more than 49° Celsius.
Observation: The water temperature was measured. In one room the temperature was measured at 52.2 degrees Celsius.
Corrective Action(s): Please ensure hot water is heated to no more than 49 degrees Celsius to comply with the legislation. Please ensure active supervision is provided until this is corrected
Date to be Corrected: May 9, 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: The staff qualifications list was observed for the facility. For one of the employees the section for references was listed as N/A.
Corrective Action(s): Please ensure references are completed for an employee prior to working in the facility.
Date to be Corrected: May 6, 2022

STAFFING: 12151 - CCLR s.19(5)(a) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (a) a criminal record check for the person.
Observation: The staff qualifications checklist was reviewed. An entry was not listed for a volunteer that was volunteering in the program. No information was given for the volunteer on site. A criminal record check was not observed.
Corrective Action(s): Please ensure the staff qualifications checklist is updated to include volunteer information for volunteers in attendance in the program.
Date to be Corrected: May 2, 2022

STAFFING: 12152 - CCLR s.19(5)(b) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (b) character references in respect of the person.
Observation: A minimum of two character references were not obtained for one volunteer.
Corrective Action(s): Please ensure volunteer qualifications are on site or that a qualifications checklist is completed with this information.
Date to be Corrected: May 2, 2022

STAFFING: 12153 - CCLR s.19(5)(c) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Immunization status was not obtained for one volunteer.
Corrective Action(s): Please ensure documentation for volunteers is on site or that a qualifications checklist is completed with the required information.
Date to be Corrected: May 2, 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: The staff qualifications list was reviewed at the facility. A criminal record check (CRC) was listed as expired for one employee. In discussion with the employee she stated that she has applied and received the CRC.
Corrective Action(s): Please ensure the staff qualifications list is updated to reflect an updated CRC.
Date to be Corrected: May 6, 2022

POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Observation: Licensing observed that no record of monthly fire drills was present in each of the school age rooms. In discussion with the staff she stated that the fire drills were completed but were not recorded.
Corrective Action(s): Please ensure to record monthly fire drills to comply with the legislation.
Date to be Corrected: May 16, 2022

NUTRITION AND FOOD SERVICES: 17120 - CCLR s.48(6) - A licensee must make available to parents information on the food and drink given to children.
Observation: Licensing observed that a menu was not posted in the facility. In discussion with the staff she said she had removed the menu and has not replaced it.
Corrective Action(s): Please ensure parents are made aware of the food and drink that is provided to their children.
Date to be Corrected: May 9, 2022

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: The children's records were reviewed. Three children were missing a date of enrollment in their record.
Corrective Action(s): Please ensure children's records are complete.
Date to be Corrected: May 16, 2022

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 reviewed the children's records. Two children's records were missing a name and phone number of a medical practitioner.
Corrective Action(s): Please ensure children's records are complete. If a child does not have a medical practitioner, the name and phone number of a medical clinic is acceptable
Date to be Corrected: May 16, 2022


Comments

At the inspection dated May 2, 2022 there were 18 children, 2 staff, and three staff and one volunteer was present. At this inspection the above noted contraventions were identified. Please correct the above noted contraventions by May 16, 2022 unless otherwise specified in the report. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy was sent to the Manager.

The following education/recommendations were provided:
-The reportable incident reporting procedure.
-The current COVID-19 protocols that are in place

The inspection findings were not reviewed with the Manager at the inspection as the Manger was absent . A copy of these documents were sent to the Manager. If you have any questions regarding this report please contact me.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
May 16, 2022

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