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Community Care Facilities Licensing

Little Twinkle Preschool/Out of School Care (Mount Lehman)
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
3551 Crestview Ave
(604) 614-5562
V2T 6T7
Balvinder Randhawa

May 02, 2018
11:30 AM
01:30 PM


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

Previous InspectionNot Applicable
Current InspectionItems reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 10050 - CCLR s.11(1) - A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation: Certificates posted however it is noted that the name of the manager is not posted within the facility. Discussion held with current manager as ECE Certificate due to expire in May , application was made to the Registry for renewal last week. Manager is aware that the renewed certificate may not arrive prior to expiry and has a plan to schedule additional staff in order to maintain appropriate staffing levels.
Corrective Action(s): Please ensure the name of the manager is posted within the facility.

Date to be Corrected: May 5, 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: 5 staff files reviewed one file did not contain verification of the Certificate issued , also noted to be found in noncompliance at a previous inspection.
Corrective Action(s): please ensure a system is developed to ensure complete staff records including the verification process.
Date to be Corrected: May 5, 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: a review of the facility policies took place noted Active Play Policy has not been developed.
Corrective Action(s): Please ensure an Active Play Policy is developed , implemented and provided to families. Visit the Fraser Health Website to access a copy of the Director of Licensing Standard of Practice - Active Play to assist you.
Date to be Corrected: May 10, 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: Policies reviewed found to not contain a screen time policy as required to be in place by Sept 2017. Facility implements computer time with the school-age program , This may be included in the facilities Screen Time Policy.
Corrective Action(s): please ensure a Screen Time policy is developed , implemented and provided to families.
Date to be Corrected: May 10, 2018

MEDICATION: 16010 - CCLR s.53(1)(a) - If a licensee has agreed with a parent to give a child any medication prescribed by a medical practitioner or provided by the parent, the licensee and his or her employees must ensure that the medication is (a) administered to the child in the amount and at the times specified by the child's parent or in the child's record or care plan.
Observation: Care plan in place for a child requiring medication , the plan lacks detail in order to guide staff in the steps to take should the medication be required to be administered . A medication administration consent form was not available to accompany the medication. The Medication was stored in a clear plastic bin out of reach of children however when the staff accessed the bin it was relocated with the medication towards the back ( no longer visible ) The child's registration form was not updated to reflect the change in required medication.
Corrective Action(s): please ensure current systems are in place to guide staff in the administration of medication , which would include authorization on part of both the family and staff to carry out the instructions as directed.
Date to be Corrected: May 5, 2018

RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure.
Observation: Attendance records did not consistently include information to indicate if children were absent , today's attendance did not accurately reflect the number of children in care as one child had been marked as absent yet was found to be present in care.
It is noted that this was also found to be in noncompliance during a previous inspection.
Corrective Action(s): please ensure a system of attendance is developed to accurately reflect whether children are absent or present and includes times of arrival / departure.
Date to be Corrected: May 5, 2018


Provided resources including amendment form for change of manager and a copy of the medication consent form.
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 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 LicensingNo action required
Due Date
May 09, 2018

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