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
CLAN-C9FQ5W

FACILITY NAME
Kingsway Christian Children's Centre - Clubhouse
SERVICE TYPES
305 Group Child Care (School Age)
303 Preschool (30 months to school age)
FACILITY LICENSE #
3201817
FACILITY ADDRESS
4045 Kingsway
FACILITY PHONE
(604) 437-3393
CITY
Burnaby
POSTAL CODE
V5H 1Y9
MANAGER
Marie Sanders

INSPECTION DATE
December 02, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
01:30 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Child Care Licensing Regulations (CCLR) and the relevant Director of Licensing Standards of Practice (DLSP). All care categories were inspected for compliance.

Contraventions
Previous Inspection - Not Applicable
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: During the inspection Licensing observed the following inside the facility:

-Only one bottle of bleach and water was being used for all of the age groups. (Corrected during the inspection)
-Two outlets were missing plug covers. This is a repeat contravention from inspection #CLAN-BAEM4K, #CLAN-BGATJC and #CLAN-BMUPQ4
-visible dirt was observed on the walls in the washroom.
Corrective Action(s): Please ensure a healthy and safe environment is provided at all times.
Date to be Corrected: Dec 3, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11020 - CCLR s.13(2) - A licensee must ensure that the community care facility and the furniture, equipment and fixtures within it are clean and in good repair while children are in attendance.
Observation: One of the soap dispensers in the washroom had tape on it. In discussion with the Manager she stated that the dispenser was broken and needed to be fixed. Two other soap dispensers were observed.
Corrective Action(s): Please ensure the facility is in good repair.
Date to be Corrected: Dec 20, 2021

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: Licensing observed the following outside and inside the facility:
-Rust on the bolts attaching the climber. This could cause a potential health hazard.
-A metal can with a sharp raw edge was located in the recycling bin at the chilren's level. This was removed during the inspection.
Corrective Action(s): Please ensure that children do not have access to any object or substance that is hazardous to their health and safety.
Date to be Corrected: December 8, 2021

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 employees.
Corrective Action(s): Please ensure staff records are complete.
Date to be Corrected: December 20, 2021

POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: During the inspection, in discussion with the Manager she stated that the emergency supplies for the facility were expired. The Manager ordered the supplies in September but they have not arrived yet
Corrective Action(s): Please ensure the facility has supplies to be prepared in case of an emergency.
Date to be Corrected: December 20, 2021

POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Observation: Licensing reviewed the record of fire drills but did not obseve a record of an evacuation drill. In discussion with the Manager she confirmed that an evacuation drill was completed but was not recorded. This is a repeat contravention from inspection: #CLAN-BAEM4K and #CLAN-BMUPQ4.
Corrective Action(s): Please ensure emergency drills are recorded to comply with the legislation.
Date to be Corrected: December 20, 2021

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: Ten children's records were reviewed: One child was missing their gender. This is a repeat contravention from inspection #CLAN-BMUPQ4
Corrective Action(s): Please ensure children's records are complete.
Date to be Corrected: December 20, 2021

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: During the inspection Licensing observed 10 children's records. One child's record was missing the date of enrollment.
Corrective Action(s): Please ensure children's records are complete.
Date to be Corrected: December 20, 2021

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: During the inspection the attendance record was reviewed. Five departure times were missing.
Corrective Action(s): Please ensure children's attendance is complete.
Date to be Corrected: December 6, 2021


Comments

At the inspection dated December 2, 2021 there were 47 children, and 4 staff and the Manager was present. At this inspection the above noted contraventions were identified. Please correct the above noted contravention by December 20, 2021 unless otherwise specified in the report. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy was sent to the Manager.

The following education/recommendations were provided:

-The reportable incident reporting procedure and forms.
-The current COVID-19 protocols that are in place

The inspection findings were reviewed with the Manager at the inspection. Due to the COVID-19 pandemic the inspection report and the risk assessment were completed at the Burnaby FHA office. The report was written in 1 hour and this is not included in the report. A copy of these documents were sent to the Manager. If you have any questions regarding this report please contact me

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Dec 20, 2021

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