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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
PGIL-D2VPR8

FACILITY NAME
St. Francis de Sales Parish Before & After School Care
SERVICE TYPES
306 School Age Care on School Grounds
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
February 27, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
0.75
ARRIVAL
02:45 PM
DEPARTURE
03:45 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: Upon review of 3 staff files, Licensing found 1 staff had a CRC completed through the RCMP and another staff's CRC was not site specific. Criminal Record Checks must be completed through the Criminal Record Check Review Program and need to be site specific.
Corrective Action(s): The Staff explained that Criminal Record Review Program will be contacted for obtaining information about the process.
Date to be Corrected:

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: Upon review of 3 staff files, 1 staff did not have copies of certificates or other evidence indicated that responsible adult training was completed.
Corrective Action(s): Please ensure that staff files are complete
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: Upon review of 3 staff files, immunization status was not obtained for one or more employees.
Corrective Action(s): Please ensure staff files are complete.
Date to be Corrected:

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: Upon review of 10 child records, 6 were missing date of enrolment.
Corrective Action(s): The Staff explained that all child records will be reviewed and updated to reflect date of enrolment.
Date to be Corrected:


Comments

At the inspection dated February 27, 2024 there were 17 children, 3 staff, and The Manager present. At this inspection the above noted contravention was identified. Licensee/Manager to provide Licensing with a written response with actions taken to bring facility into compliance. The Licensing Officer will review the response. As part of this Routine Inspection a Facility Risk Assessment Tool will be completed and a copy will be provided.

The following was discussed:
· Transfer of care procedures

The following resources were provided:
· Your Checklist
· LO’s business card
· Child Records
· Fraser Health: Employee Immunization Status form
· Reportable Incident Bulletin

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 LicensingNo action required
Due Date
Mar 12, 2024

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