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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EGAU-BGJQ4M

FACILITY NAME
CEFA Meadowtown
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
TDAH-AMPL3C
FACILITY ADDRESS
115 - 19800 Lougheed Hwy
FACILITY PHONE
(604) 459-9990
CITY
Pitt Meadows
POSTAL CODE
V3Y 2W1
MANAGER
Jasmin Sagoo-Lally

INSPECTION DATE
October 01, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
08:45 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 (DLSP). All areas of the facility were inspected for compliance.

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
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: Licensing reviewed 6 staff files and observed that there was no record of a criminal record check (CRC) clearance letter for one staff. The interim manager advised that the staff member has not been working alone with children. During the inspection the interim mamager re-sent the application for the CRC.
Corrective Action(s): Please ensure CRC's are abtained prior to employment.
Date to be Corrected: October 31, 2019

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 reviewed 6 staff files and observed that there was no evidence to confirm that character references were checked for 3 staff; a list of names and phone numbers were provided.
Corrective Action(s): Please ensure evidence of character reference checks if only phone numbers are provided.
Date to be Corrected:

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: Licensing reviewed 6 staff files and observed that there was no record of immunization status for 2 staff.
Corrective Action(s): Please obtain records of immunization statuses prior to employment.
Date to be Corrected: October 4, 2019

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: Licensing reviewed 6 staff files and observed that the criminal record check clearance letter for one staff was referenced to the previous place of employment. The interim manager advised that application for a new criminal record check was already submitted.
Corrective Action(s): Please ensure current records.
Date to be Corrected: October 31, 2019

CARE AND/OR SUPERVISION: 14030 - CCLR s.34(2)(b) - Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Observation: At the time of the inspection, the following was identified in regards to staffing:
> There was no ITE in CEFA Baby A. Present were an ECE and an ECE Assistant with 6 children. The interim manager stated that the ITE staff was scheduled to start at 9:15 a.m.
> There was no ECE in CEFA Baby B. Present were an ITE and ECE Assistant with 7 children. This was corrected during the inspection when an extra ECE staff stepped into the program.
Corrective Action(s): Please ensure appropriate staff to child ratios as per Schedule E of the CCLR
Date to be Corrected: Oct 2, 2019

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: Licensing reviewed children’s records and observed that 2 children in care require care plans to address a medical condition.
Corrective Action(s): Please develop care plans in consultation with parents.
Date to be Corrected: October 4, 2019


Comments

Summary of Inspection

At this inspection the above noted contraventions were identified. Licensing provided dates for correction and is requesting a written response by October 2, 2019 advising on compliance with coded item number 14030. Licensing will conduct a follow-up inspection to confirm compliance with staffing.

As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.

The following was discussed:
Promoting Active Play in the program
Active Supervision
Lead in the Water
Section 34 (4) of the CCLR
Schedule E of the CCLR
Different ways to capture record of yearly earthquake drill


The following resources were provided:
Reportable Incident Bulletin
Fact sheet- Lead in drinking water

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

Present for the inspection was an interim manager. The report was also reviewed with the interim manager.

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
Oct 01, 2019
Approximate Follow Up Date

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