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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SWAR-APLRKQ

FACILITY NAME
CEFA Walnut Grove
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
DMIL-9U4N44
FACILITY ADDRESS
100 - 19950 88th Ave East
FACILITY PHONE
(604) 881-2332
CITY
Langley
POSTAL CODE
V1M 0A5
MANAGER
Rebecca Medeiros

INSPECTION DATE
July 25, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
08:45 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 (DLSOP).
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
Policies and Procedures
Care and supervision/Hygiene and medication
Nutrition
Program
Child Records and reporting

As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy is provided to the facility.
The Risk Assessment includes any non-compliance identified during the routine inspection and a 3 year ‘historical’ review of the facility’s compliance and operation and is used to determine inspection frequency.

Visit the CCFL website at http://www.fraserhealth.ca/childcare
for additional resources, and links to the Legislation (CCALA and CCLR)
Useful websites to consider:
Regulations and Act at www.health.gov.bc.ca/ccf
Criminal Records Checks at www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
Healthlink BC at https://www.healthlinkbc.ca/hlbc/files/documents/healthfiles/hfile69e.pdf

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: 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:
- a staff member attempt to take a group of 3 children through the commercial kitchen space to access an area outside the facility play area. This space should not be accessible to children as it is not 'child proof' and there are many hazards in that space. Children would need to walk past a high shelving system that was not secured to the wall and contained many pieces of kitchen equipment that could potentially harm a child should it fall from the shelving.
- Paint stripper was observed to be in a cupboard in the art room. This cupboard, and the room was accessible to children as the room had an open door. Licensee stated that the art room is not in use for the Summer although staff can access its' contents.
Corrective Action(s): - Please ensure that children do not have access to hazardous materials whilst in care.
Date to be Corrected: Immediately

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11280 - DLSOP Safe Play Space (play space design [b2]) - [bullet 2] The licensee must ensure that any equipment provided is placed to reduce direct exposure to sun. Equipment such as slides may become too hot to use during certain times of the day if they are sited poorly.
Observation: Licensing observed in the Group Child Care under 36 months playground that there was no sun shade for the children. Licensee stated that the canopies/shades regularly used had been taken down over the Winter and not replaced.
Corrective Action(s): Please ensure consideration is given to any area where there is direct sunlight and that shade is provided for the children.
Date to be Corrected: August 4th 2017

HYGIENE AND COMMUNICABLE DISEASE: 15030 - CCLR s.46(1) - A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
Observation: Licensing observed that the children use assigned hand towels in the bathroom which are placed on a row of hooks for the children to access. Licensing is concerned that cross contamination is taking place as the towels actually touch one another whilst hanging and Licensing also observed 2 children 'sweeping' their hands along the row of towels after coming out of the toilet before washing hands.
Corrective Action(s): Please ensure health and hygiene practices are used by finding an alternate method for children to dry their hands after bathroom use.
Date to be Corrected: July 27th 2017

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 (CORRECTED DURING INSPECTION): Licensing reviewed attendance records for 3 programs and observed that 2 programs were incomplete with some missing a departure time
Corrective Action(s): Please ensure that accurate attendance records are kept at all times. Licensee holds digital attendance records for the facility - reviewed with Licensing.
Date to be Corrected: July 27th 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: On review of a random selection of children's emergency information in each of the program rooms, Licensing observed that 5 were missing digital images. Licensee discussed their ability to update information through an electronic app which is used to communicate to families as well as store information, as a method of holding this information.
Corrective Action(s): Please ensure that all information is current in a child's file, including a digital image, prior to their first day at the facility.
Date to be Corrected: August 4th 2017

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: Licensing observed medication for a child requiring extra support in one of the programs' backpack for the staff to access. There was no care plan in place for this child which would direct the staff with signs and symptoms to look out for and recommended action.
Corrective Action(s): Please ensure that any child requiring extra support has a care plan developed which provides information for staff as to how to effectively care for their needs
Date to be Corrected: July 27th 2017

RECORDS AND REPORTING: 19250 - CCLR s.58(2)(a) - The licensee must (a) develop the care plan in consultation with a parent of the child requiring extra support and any person requested by the parent.
Observation: Licensing reviewed a care plan for a child requiring extra support that did not indicate a date of preparation or whether the parents were consulted in its creation.
Corrective Action(s): Please ensure any care plan created is done so with consultation of the parents and when it was created. This ensures that the staff are getting the correct information as to how best meet the childs' needs and on annual review, whether the needs have changed.
Date to be Corrected: July 27th 2017


Comments

The operation of the facility is in compliance with current regulations of the Community Care and Assisted Living Act (CCALA) and the Child Care Licensing Regulation (CCLR) apart from any listed above

On site today was the Licensee to assist Licensing with facility files. The Manager was absent today.
Staff to child ratio was in compliance with regulations
Physical facility exemptions and temporary retentions are in place
Programming is posted and available for parent review and the facility is running themed programs during the Summer.

Licensing observed Staff engaged with children using appropriate guidance techniques and language. Staff were attentive to children's needs and supervision was maintained at all times.
Licensing observed the children in a variety of activities throughout the facility including; snack time (provided by the facility), circle time in several programs and outdoor play for all programs on a scheduled basis. Outdoor space in the Infant/Toddler playground is utilized by 2 programs at the same time as space allows.

Discussions with the Licensee:-
- Licensing reviewed the staffing systems in place with the Licensee and new ways of ensuring all documentation is complete. Licensee also provided a copy of the new record of prepayment that the facility will now use. Active Play and Screen Time policies will be submitted to Licensing prior to September 2017 in light of the Director of Licensing Standards of Practice for Active Play.
- Licensing provided information regarding the intent of care plans to be made in consultation with parents.
- Licensing recommends removing all topical treatments/alcohol wipes from the first aid kits unless parental permission is sought to administer.
- Also discussed the advertising of programs - please ensure the words 'Summer Camp' are not used to describe current programs as this can be misleading.

A response in writing is required to be submitted to Licensing by the date below, outlining how the contravention(s) have been addressed.
A follow up inspection may be conducted due to the number and nature of the contraventions.

This inspection report was reviewed with the Licensee prior to report writing and again, later in the afternoon on delivery.
If you have any concerns or further questions regarding the content of this report, please contact your Licensing Officer. (Contact details provided)
Thank you for your time today
Report was written off-site due to time constraints - 1 hour

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
Aug 04, 2017

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