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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
ANAI-BYSU29

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)
303 Preschool (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
March 03, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.25
ARRIVAL
08:45 AM
DEPARTURE
10:00 AM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unannounced 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 areas of the facility were inspected for compliance with a focus on health and hygiene practices during the COVID-19 pandemic.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 10020 - CCLR s.10(2)(a) - Licensees must not make any structural change to a community care facility unless the licensee first (a) submits plans for the change to a medical health officer.
Observation: Licensing observed the preschool class had been moved the "gym" area. A clarifying conversation with the manager indicated that the classroom floors were being replaced, therefore the children's equipment had been moved. The licensee did not inform or provide licensing with a plan prior to the work commencing.
Corrective Action(s): Ensure that licensing is informed of any changes to the community care facility via submission of plans.
Date to be Corrected: March-6-2021.

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: Licensing observed some wear and tear on the walls in the under 3 and over three classrooms.
Corrective Action(s): Ensure that the community care facility is in good repair.
Date to be Corrected: March-17-2021

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 medicated cream in an unlocked cupboard in the under three children's bathroom.
Corrective Action(s): Ensure children do not have access to substance that may be hazardous to their health and safety.
Date to be Corrected: March-3-2021

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: Upon an inspection of 6 staff files, it was noted that one staff's criminal record check had expired in 2018.
Corrective Action(s): Ensure that a valid criminal record check is obtained for each employee before the start of employment.
Date to be Corrected: March-10-2021

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: Upon an inspection of 6 staff files, Licensing observed that 2 files were missing character references.
Corrective Action(s): Please ensure staff files are complete as per legislative requirements before start of employment.
Date to be Corrected: March-10-2021

POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must have all of the following: (b) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: Licensing observed that all fire extinguishers were past due for servicing.
Corrective Action(s): Ensure that equipment required to mitigate, respond to and recover from any emergency is kept up to date.
Date to be Corrected: March-10-2021

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 observed that the February fire drill had not been logged.
Corrective Action(s): Ensure that fire drills are logged.
Date to be Corrected: March-3-2021

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: Upon an inspection of 6 children's files, Licensing observed that one was missing a medical insurance plan number.
Corrective Action(s): Ensure children's files are complete.
Date to be Corrected: March-10-2021

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: Licensing inspected 6 children's files and noted that 2 files were missing the name and telephone number of a medical practitioner.
Corrective Action(s): Ensure children's files are complete as per legislative requirements.
Date to be Corrected: March-10-2021


Comments

Summary of Inspection:
At the inspection dated March-3-2021, there were 21 children in care with 7 staff members.
At the inspection, the above noted contraventions were identified.
Please provide Licensing with a written response, by the date noted below, stating how the identified contraventions will be addressed in order to ensure year round compliance.
As part of this Routine Inspection a Facility Risk Assessment Tool was completed.
This report was written off site due to COVID-19 safety practices. The contraventions identified in the report were reviewed with the Manager before Licensing's departure.
A copy of the report and the corresponding Risk Assessment was emailed to the Manager.
The following items were discussed:
-Planned emergency response during COVID-19.
-Ensuring that medication which has been specified in children's care plans is accessible by care givers in an emergency.
-Licensing recommends that the outdoor play space be power washed playground equipment has been exposed to winter conditions.
-Conversation re: legislative requirements for staff records.
-Communicable disease prevention practices.
-Health/hygiene/sanitizing practices during COVID-19 which included review of cleaning and sanitizing as multiple steps and review of proper diapering practices.
Licensee Resources:
- Visit the CCFL website at www.fraserhealth.ca/childcare for forms, resources and links to Legislation (CCALA and CCLR).
- For immediate assistance, reporting of serious incidents including COVID-19 concerns, you may call the duty line at 604-587-3936.
-Updated information on COVID-19 can be found at:
BCCDC: http://covid19.bccdc.ca/?utm_campaign=20200403_GCPE_AM_COVID_5__ADW_BCGOV_EN_BC__TEXT
Fraser Health:

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
Mar 24, 2021

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