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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
ABEY-ARLT6X

FACILITY NAME
1st Step Montessori Inc - Sunbury Hall
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
MLAO-A92NPK
FACILITY ADDRESS
10409 Dunlop Rd
FACILITY PHONE
(604) 417-3290
CITY
Delta
POSTAL CODE
V4C 2L1
MANAGER
Randeep Bal

INSPECTION DATE
September 27, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
01:30 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
17

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 (DLP). Evidence for this report was based on the licensing Officers 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, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Programming, Records and Reporting
As part of the Routine Inspection a Facility Risk Assessment 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 .environment
Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)

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: There are two staff who work with children who do not have a criminal record check from the criminal record review program, although there are CRCs from previous employers.
Corrective Action(s): Ensure CRCs are obtained from the CRC review program prior to staff working with children.
Date to be Corrected: 29-Sep-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: There is one staff who does not have record of reference checks.
Corrective Action(s): Ensure references are checked for each staff prior to working with children.
Date to be Corrected: 15-Oct-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: There is one staff who does not have a record of immunizations.
Corrective Action(s): Ensure a record of immunization has been obtained for each employee.
Date to be Corrected: 15-Oct-2017

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: Staff stated that they had not been trained in or practiced the emergency evacuation procedure.
Corrective Action(s): Ensure staff are trained in implementing the emergency plan.
Date to be Corrected: 15-Oct-2017

STAFFING: 12190 - CCLR s.22(2)(b) - A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.
Observation: A review of fire drill records shows that a fire drill for the month of June was not practiced in either program.
Corrective Action(s): Ensure fire drills are practiced each month.
Date to be Corrected: 31-Oct-2017

POLICIES AND PROCEDURES: 13071 - CCLR s.56(2) - A licensee must ensure that the policies and procedures referred to in subsection (1) are implemented by employees.
Observation: A review of the log book showed that there was one child in attendance for several days while sick.
Corrective Action(s): Ensure that the policies and procedures are followed by employees.
Date to be Corrected: 15-oct-2017

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: There is one child who requires medication, however there is no medication consent in place that spacifies the time or amount of the medication to give to the child.
Corrective Action(s): Ensure that medication consent forms are in place for any medication provided by a parent.
Date to be Corrected: Prior to this child being in care again.

RECORDS AND REPORTING: 19220 - CCLR s.58(1)(b) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (b) the courses of action recommended by health care professionals to address the needs of the child requiring extra support.
Observation: There is a child in care who requires extra support, however there is no care plan in place.
Corrective Action(s): Ensure a care plan is in place for any child that requires extra support.
Date to be Corrected: prior to this child being in care again.

RECORDS AND REPORTING: 19320 - CCLR s.59(a) - In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58.
Observation: One staff does not have records at this facility.
Corrective Action(s): Ensure staff records are kept na single place at the faciity.
Date to be Corrected: 29-Sep-2017


Comments

The active play standards of practice is implemented at this facility; there are two outside play times per day and screen use is not permitted.

The children were seen to eat a healthy snack, play with toys and engage with the caregivers. The staff were seen to speak in encouraging gentle voices, guide problem solving and guide hand washing before eating snack, smile with the children and provide choices. The facility is clean and in good repair. There is evidence of ensuring compliance to the legislation.

Thank you for your assistance with this inspection - staff were very helpful. Immunization posters were provided 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
Oct 06, 2017

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