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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

JMIA-CND264

FACILITY NAME Alexandra Neighbourhood House Children's Centre at Crescent Park		SERVICE TYPES 305 Group Child Care (School Age)	FACILITY LICENSE # KPUL-BHLN44
FACILITY ADDRESS 2440 128th St			FACILITY PHONE (604) 560-5520
CITY Surrey	POSTAL CODE V4A 3G2		MANAGER Stacey St. Hilaire

INSPECTION DATE January 23, 2023	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 1
ARRIVAL 03:30 PM	DEPARTURE 04:45 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) and 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

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: No evidence of CRC's available for review.
Corrective Action(s): Ensure staff files are current and information available for review.
Date to be Corrected: January 30, 2023

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: No evidence of checked references available for review.
Corrective Action(s): Ensure staff files are current and information available on site
Date to be Corrected: Jan 30, 2023

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: No evidence of a resume/work history available for review.
Corrective Action(s): Ensure Staff files are current and available
Date to be Corrected: January 30, 2023

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: No evidence of immunization records available for review.
Corrective Action(s): Ensure staff files are current and information is available.
Date to be Corrected: January 30, 2023

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 review of the onsite policies and procedures (family handbook) indicates that there is not a specific washroom use/supervision policy in place for School Aged Children. During today's inspection, licensing discussed current practice that is occurring at the facility when children have to leave the classroom to use the washroom or wash their hands. Two children did leave the classroom together today, and were heard by licensing to be quite loud and away for 4-5 minutes, the next time these children left one child did obtain a small injury.
Corrective Action(s): A policy will ensure children are safe and active supervision is in place.
Date to be Corrected: January 30, 2023

Comments

Summary of Inspection:

At the inspection dated January 23, 2023 there were 7 children and one staff present.
At this inspection the above noted contraventions were identified.
Action required by the licensee includes providing a written response by January 30, 2023
Actions required by Licensing include reviewing the written response and conducting a follow up inspection.

As part of this Routine Inspection, a Facility Risk Assessment Tool was completed.

The following discussions were had;

- Ensuring children's belongings are stored safely and individually
- Active Supervision- practices
- Log books- injuries, illnesses and unusual events (also document when parents notified)
- Review of facility contact information- email address and phone number
- Reportable Incident Reporting –Duty Line 604-587-3936.

The following resources to be emailed;

· Children's Records
· Active Supervision Bulletin

This inspection report was reviewed with the staff and a copy of both the report and Risk Assessment were provided to the facility at the time of inspection.
Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).

Please contact me if you have any questions or concerns.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	Follow-up Inspection Required
Due Date Jan 23, 2023	Approximate Follow Up Date

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