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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CGEE-AHAQFA

FACILITY NAME
St. Alban's The Martyr Day Care
SERVICE TYPES
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
3274013
FACILITY ADDRESS
7717 19th Ave
FACILITY PHONE
(604) 522-6228
CITY
Burnaby
POSTAL CODE
V3N 1E8
MANAGER
Pam Venketaya

INSPECTION DATE
January 04, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
09:30 AM
DEPARTURE
11:30 AM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
24

Introduction

An unscheduled routine inspection of this community care facility (CCF) was conducted by the licensing officer (CCFL) to assess compliance w/ the:
• Community Care & Assisted Living Act (CCALA)
• Child Care Licensing Regulation (CCLR)
• Director of Licensing Standards of Practice (DLSP)

At the time of inspection, evidence for this facility inspection report (FIR) was based upon:
• CCFL's observations
• CCFL's review of the CCF's records
• information provided to CCFL by employees

CCFL reviewed these 10 areas today:
• licensing
• physical facility
• staffing
• policies & procedures
• care & supervision
• hygiene & communicable disease control
• medication
• nutrition & food services
• program
• records & reporting

As part of this inspection, CCFL completed & provided a risk assessment tool, which includes:
• any noncompliance identified
• the CCF's 3-year compliance & operational history since 2014/01/04

Please visit http://www.fraserhealth.ca/child-care/ for:
• links to the CCALA, CCFL, & DLSP
• the temporary placement/retention application form
• the exemption application form
• additional resources

Contraventions
Previous Inspection - Contraventions observed on FIR #EGAU-A3XNA8 have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 10070 - CCLR s.11(4) - A licensee must display in a prominent place in the community care facility the certificate, or a copy of the certificate, of any educator or assistant employed to work in the community care facility.
Observation: A new employee's ECE certificate wasn't posted conspicuously w/ her colleagues' certificates.
Corrective Action(s): Please ensure all employees' certificates are posted in an easily viewable location.
Date to be Corrected: 06-Jan-2017

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: 2 employees lacked this in their file.
Corrective Action(s): Please ensure all requirements of §19(1) are obtained by employees' 1st day of employment.
Date to be Corrected: 06-Jan-2017

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: 1 employee lacked this in her file.
Corrective Action(s): Please ensure all requirements of §19(1) are obtained by employees' 1st day of employment.
Date to be Corrected: 06-Jan-2017

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: 2 employees lacked this in their file.
Corrective Action(s): Please ensure all requirements of §19(1) are obtained by employees' 1st date of employment.
Date to be Corrected: 06-Jan-2017

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: An employee lacked this in her file.
Corrective Action(s): Please ensure all requirements of §19(1) are obtained by employees' 1st date of employment.
Date to be Corrected: 06-Jan-2017

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: An employee lacked this in her file.
Corrective Action(s): Please ensure all requirements of §19(1) are obtained by employees' 1st date of employment.
Date to be Corrected: 06-Jan-2017

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: A new employee's required documents (CRC, work history, references, ECE certificate, immunization status) weren't available for CCFL's review. The manager was unable to locate these @ the time of inspection.
Corrective Action(s): Please ensure all requirements of §19(1) are obtained & attainable @ the CCF prior to employees' 1st day of employment.
Date to be Corrected: 06-Jan-2017

NUTRITION AND FOOD SERVICES: 17120 - CCLR s.48(6) - A licensee must make available to parents information on the food and drink given to children.
Observation: The licensee hasn't posted this month's lunch & snack menu yet.
Corrective Action(s): Please ensure parents have access to this information.
Date to be Corrected: 06-Jan-2017

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: CCFL reviewed 10 children's records & found that 1 lacked their enrolment date.
Corrective Action(s): Please ensure all requirements of §57 are obtained by children's 1st date of care.
Date to be Corrected: 06-Jan-2017

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: Although there are photos available in the CCF, they're unavailable when children are taken offsite for fieldtrips (not on the emergency consent cards or in employees' phones).
Corrective Action(s): Please ensure all requirements of §57 are obtained by children's 1st date of care.
Date to be Corrected: 06-Jan-2017

RECORDS AND REPORTING: 19370 - DLSOP Safe Play Space (maintenance of equipment [b3]) - [bullet 3] Keep a log of all inspections, maintenance and repairs.
Observation: Inspections (daily, monthly, annual), maintenance, & repairs to the outdoor play space aren't documented.
Corrective Action(s): Please ensure accurate record keeping. CCFL suggested documenting these on the daily attendance sheets.
Date to be Corrected: 06-Jan-2017


Comments

CCFL:
• observed compliance today, w/ the exception of the abovenoted violations
• provided Live 5-2-1-0 info & discussed its key messages w/ the manager
• discussed the requirements of the new DLSP (Active Play) w/ the manager
• reviewed this FIR w/ the manager prior to signing & printing
• thanks the manager & employees for their time & assistance today

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
Jan 18, 2017

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