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
DCAR-AYRMSZ

FACILITY NAME
Blueridge Preschool Ltd.
SERVICE TYPES
302 Group Child Care (30 months to school age)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
0782690
FACILITY ADDRESS
3459 Goldfinch Street
FACILITY PHONE
(604) 870-8878
CITY
Abbotsford
POSTAL CODE
V2T 6Y5
MANAGER
Inderpreet Sahota

INSPECTION DATE
May 11, 2018
ADDITIONAL INSP. DATE (multi-day)
May 14, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
09:45 AM
DEPARTURE
11:15 AM
ARRIVAL
01:15 PM
DEPARTURE
01:45 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

Contraventions
Previous InspectionContraventions observed on FIR #SCLY-ARLSAB have been corrected except for those noted on supplementary pages.
Current InspectionItems reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 10010 - CCLR s.10(1) - Applicants for licences and licensees must notify a medical health officer immediately of any change in the information provided under section 9.
Observation: Staff described her position while working in the tutoring program , staff was unfamiliar with the term GCC ( School-age ) - see comment section of this report for a full description of the program. Prior to a licence being issued the manager provided within the application a detailed description of the care programs offered. It is determined that this description no longer meets the type of program as described by staff and confirmed by the manager to operate as a " tutoring " club. Notification to this change of service was not provided to Licensing.
Corrective Action(s): amendment form forwarded by email in order to remove Group Child Care ( school-age ) from the facility licence. The manager was informed that the exempted " Tutoring " program may continue to operate.
Date to be Corrected: May 15, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11080 - CCLR s.15(1)(a) - A licensee must supply equipment, furniture and supplies that are (a) of sturdy and safe construction, easy to clean and free from hazards.
Observation: Preschool room is equipped with 2 toilets , 2 sinks however one of the washrooms as stated by staff is the designated staff washroom , a purse was hanging in this space and a vacuum cleaner was stored in the area. The staff stated if the children needed to use a 2nd washroom that they could access the washroom located in the GCC ( 30 mos - school-age ) side. It was noted that this practice was not observed as children were reminded to return to the preschool class when they attempted to access this area.

Corrective Action(s): It is noted that storage of staff personal belongings such as purses has been discussed at a previous inspection , provide your plan to ensure children have ongoing access to these areas which must be free from hazards and safe for use.
Date to be Corrected: May 15, 2018

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: Cleaning supplies stored on a lower ledge and on the floor within the children's washroom is accessible to children. It is noted that storage practices related to hazardous items has been identified in noncompliance at a previous inspection - DCAR- AFDSU6
Several exposed electrical outlets within the GCC ( 30 mos - school-age ) room were accessible to children , the door to this room was open and children were observed entering this space.
Corrective Action(s): ensure a system is developed which addresses unsafe storage practices of items / substances which if accessed may cause serious risk of harm to children.
Date to be Corrected: May 11, 2018

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: Criminal Record Clearance had not been obtained for a staff working within the preschool , the manager stated it had been applied for however not yet received. Also identified in noncompliance in a previous inspection - SCLY-ARLSA8
Corrective Action(s): Staff are required to be fully screened prior to working with children , please forward evidence that you have complied with this requirement and developed a system to assist you in ensuring the screening process is complete. Child Care Links - Records is a suggested resource which includes a checklist for your use.
Date to be Corrected: May 15, 2018

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: Immunization status missing for 1 staff , also noted the first aid certificate for this staff expired April 18, 2018. The staff confirmed renewal to occur May 19, 2018.Observed another staff working today with valid first aid.
Corrective Action(s): please ensure children have at all times access to staff who hold current first aid training and that staff screening is complete to include immunization status Forward staffing schedule to include requirement is met ( May 15, 2018 ) prior to renewal along with a copy of the completed first aid training to demonstrate renewal is complete.
Date to be Corrected: May 20, 2018

STAFFING: 12140 - CCLR s.19(4)(a) - A licensee must not employ a person in a community care facility as (a) an educator or an assistant unless the person holds a certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry,
Observation: Records for staff who hold ECE certification do not include the required verification
Corrective Action(s): please ensure verification is completed using the system established and maintained by the Director of the ECE Registry.
Date to be Corrected: May 15, 2018

STAFFING: 12180 - CCLR s.22(2)(a) - A licensee must ensure that each employee (a) is trained in the implementation of the fire drill system and emergency plan described in subsection (1), including the use of any equipment noted in the fire drill system and emergency plan.
Observation: Fire Extinguisher overdue for servicing expired - March 31, 2018
Corrective Action(s): please ensure annual servicing occurs of equipment as identified in the fire drill system and emergency plan
Date to be Corrected: May 25, 2018

POLICIES AND PROCEDURES: 13100 - DLSOP Active Play - The Licensee must develop and implement an Active Play Policy to engage children in daily active play, consisting of un-facilitated play and facilitated games and activities.
Observation: Active Play Policy was not known to staff and could not be located within the facility. The children were observed participating in outdoor time after the Licensing Officer encouraged staff to carry out their daily programming as planned prior to inspection.
Corrective Action(s): please ensure Active Play policy is developed , implemented and provided to families - resources were provided during a previous inspection effective date of implementation as set by the DOLSOP Sept 2017.
Date to be Corrected: May 20, 2018

POLICIES AND PROCEDURES: 13120 - DLSOP Active Play - The Licensee must develop and implement a Screen Use Policy to guide employees in the use of screen time activities.
Observation: Screen Time Policy is not yet developed - resources provided to the manager in a previous inspection.
Corrective Action(s): please ensure Policies are complete to include updates and the creation of additional policies as required in this case effective deadline Sept 2017
Date to be Corrected: May 20, 2018

CARE AND/OR SUPERVISION: 14010 - CCLR s.34(1) - A licensee must ensure that children are adequately supervised by qualified employees in sufficient numbers to meet the needs of each child.
Observation: 17 children attending the preschool program in the care of 2 staff , 1 ECE and 1 Responsible Adult. Staffing Schedule reflects this is a regular staffing pattern maintained at the facility. The Responsible Adult was observed to carry out housekeeping duties effectively however did not demonstrate or model language skills for preschool age children for example using the word No , did not get down to child's level.
Corrective Action(s): Reviewed staffing requirements with manager as set out in Schedule E of the CCLR, Manager asked if this staff could continue to be used in the preschool as a helper which would be suitable however not to be included in ratio.
1 ECE - 10 children
1 ECA - 11-20 children.
Please submit your staffing schedule to support these requirements.
Date to be Corrected: May 14, 2018

RECORDS AND REPORTING: 19070 - CCLR s.57(2)(a) - A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: It is noted that Staff did not have access to any records pertaining to the Group Child Care ( School-age ) Program, Staff who works with the school-age program included that she is not aware of such files as she carries out the tutoring program with the children. In review of 6 preschool registration files 4 were missing Medical insurance numbers and 1 missing Immunization status.
Corrective Action(s): Ensure a system is developed to capture required documentation including medical insurance numbers and immunization status.

Date to be Corrected: May 20, 2018

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: Six children's registration files audited , 1 of 6 missing name and contact number for the medical practitioner.
Corrective Action(s): please ensure systems are in place to ensure complete children's registration files including Dr contact information.
Date to be Corrected: May 20, 2018

RECORDS AND REPORTING: 19160 - CCLR s.57(2)(i) - A licensee must keep, for each child, a record showing the following information: (i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency.
Observation: 4 of 6 children's registration files did not contain photos and digital image was not available.
Corrective Action(s): please ensure children's registration files are complete with all required documentation , by having current photos in place children may be identified in case of an emergency. It is noted that contraventions realeted to incomplete documentation of children's records have been previously identified in past inspections which supports the need for a systems review to improve record keeping practices.
Date to be Corrected: May 20, 2018


Comments

Licensing arrived to complete the inspection , 17 children present in the Preschool program with 2 staff. The manager was not on site , staff contacted the manager by phone and the manager requested to speak with the licensing officer. The manager was outside of the community and offered to return to the facility , while this was not required Licensing completed the report off site after speaking first with the manager in order to review the identified contraventions and to inform the manager of the requirement to amend the licence to accurately reflect the programs operated. The Staff qualified as a Responsible Adult included that she works in the tutoring program when not scheduled to assist in the preschool class. The staff described the tutoring program as follows :
4 Children attend for 1 hour intervals for the purpose of tutoring. ( focus is on tutoring , completing journals and staff assign homework.)
The parents leave the site and return to pick up their children after 1 hour.
Snack and outside time does not occur.
Program operates Monday - Thursdays afternoons only. 3:30 - 6:30 pm
Licensing connected with the manager by phone and confirmed the description of the School-age program as described by the staff as a tutoring program. The manager confirmed the description and requested the program continue to operate until the end of the school year.
Licensing explained that the " Tutoring " program can continue to operate as an exempt program as it does not fit the definition of a Licensed Group Child Care ( School-age ) program. An Amendment Form was forwarded by email in order to amend the licence to remove the GCC ( School-age )effective immediately.
Records and past inspection reports conclude that the Group Child Care ( 30 mos - school-age ) program which is currently licensed for 5 children also has not operated within the past year , manager included that 4 children will be attending in the upcoming month.
Licensing arranged with the manager to provide and review a full written report on Monday May 14, 2018.


As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at http://www.fraserhealth.ca/childcare for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)
Should you have any questions pertaining to this report please feel free to contact me
Licensing Officer
Community Care Facilities Licensing

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
May 25, 2018
Approximate Follow Up Date
08 Jun, 2018

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