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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
WBET-CSQNCL

FACILITY NAME
Three Bears Centre
SERVICE TYPES
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
HRUN-BW7SUP
FACILITY ADDRESS
9887 Cameron St
FACILITY PHONE
(604) 444-3302
CITY
Burnaby
POSTAL CODE
V3J 1M3
MANAGER
Shazleen Sahukhan

INSPECTION DATE
June 12, 2023
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
# OBSERVED IN CARE

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). 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11010 - CCLR s.13(1) - A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.
Observation: Mr Clean is used to clean the facility. This product does disinfects but does not sanitize. This is repeat noncompliance and was noted on routine inspection #WBET-CERQ8Z.
Corrective Action(s): Please ensure a product that sanitizes is used in the facility.
Date to be Corrected: June 23, 2023

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 (CORRECTED DURING INSPECTION): Medication was being stored in a cubby and was accessible to children.
Corrective Action(s): The medication was removed during this inspection.
Date to be Corrected:

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: A criminal record check for one staff was not obtained through the sharing program of the Criminal Record Review Agency (CCRA).
Corrective Action(s): If a criminal record check is not site specific a copy must be obtained through the sharing program of the CRRA.
Date to be Corrected: June 23, 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: Evidence of references being checked is not available and one staff has one reference instead of the required two.
Corrective Action(s): Please ensure all staff have a minimum of two references (the manger needs three) and that evidence of the references being checked is available.
Date to be Corrected: June 23, 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: A record of the person's work history was not obtained for one.
Corrective Action(s): All employees (including substitute staff) need to have a resume on file.
Date to be Corrected: June 23, 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: Immunization status was not obtained for one employee.
Corrective Action(s): All staff (including substitutes) must have immunization status on file.
Date to be Corrected: June 23, 2023

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 system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: An ECE certificate for one staff has not been validated.
Corrective Action(s): Please ensure all ECE certificates are validated.
Date to be Corrected: June 23, 2023

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: Files for 10 children were reviewed. A start date was missing for two files.
Corrective Action(s): Please ensure a start date is available for all children.
Date to be Corrected: June 23, 23023

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: Files for 10 children were reviewed. An emergency contact person was not available in one file and contact information for a doctor or medical clinic was not available in two files.
Corrective Action(s): Please ensure all files contain the required information.
Date to be Corrected: June 23, 2023

RECORDS AND REPORTING: 19210 - CCLR s.58(1)(a) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (a) the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.
Observation: A care plan is not available for a child requiring extra support.
Corrective Action(s): Please ensure a care plan is available for all children who require extra support.
Date to be Corrected: June 16, 2023


Comments

Summary of Inspection
At the inspection dated June 12, 2023 there were 20 children and three staff present. At this inspection the above noted contraventions were identified. The Licensee will take action to bring the facility into compliance and provide a written response to the Licensing Officer. The Licensing Officer will review the response. As part of this routine inspection, a facility risk assessment tool is completed and a copy is provided. This report was reviewed with the manager, written on site and a copy emailed to the manager.
The following were discussed
Unless required by the facility, a hard copy of a child's immunization record is not required by the legislation.
The parent handbook quotes Section 21(a) CCLR in regards to a child's immunization status. The handbook needs to be updated to show the correct section of the CCLR.
Having a system in place to update children's files as required.
Substitute staff must be fully screened.
Bottles of cleaning solution need to be accuralty labeled.
Bleach should not be mixed with any other cleaning products.
The following resources were provided:
Staff qualifications/documentation checklist.
Medication administration consent form.
Anaphylaxis emergency form.
ยท 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
Jun 23, 2023

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