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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
ONIR-CCEPK8

FACILITY NAME
Twelfth Avenue Neighbourhood Care
SERVICE TYPES
305 Group Child Care (School Age)
FACILITY LICENSE #
NGIL-95HRCD
FACILITY ADDRESS
7622 12th Ave
FACILITY PHONE
(604) 431-0400
CITY
Burnaby
POSTAL CODE
V3N 2K1
MANAGER
Sandip Singh

INSPECTION DATE
March 10, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.5
ARRIVAL
02:30 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
11

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 (DoLSoP). 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: 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: At the inspection from February 02, 2018, inspection report #SMOY-AVLVBG and inspection from Janaury 02, 2019, inspection report #SMOY-B82VQQ the facility was found in violation of this section as the outdoor decking in front of the facilities door was bubbling and lifting. The program uses this area to enter and exit the facility.
At today's inspection the following was observed:
- the bubbling in front of the door tore apart and the wood underneath is exposed.This is a tripping hazard.
- the wooden stairs leading to the facility are beginning to rot and wood is chipping away from the stair. Two steps are sinking and are a hazard to parents and children entering the facility.
- inside of the facility, in the staff bathroom the ceiling has an area exposed. A piece of tape was covering the missing ceiling piece. The tape has come appart and insulation is showing.

The facility manager stated that she has reported the issues named above to the maintenance department, however the issue remains outstanding.
Corrective Action(s): Please ensure that the facility is in clean and good repair.
Date to be Corrected: Please submit a written plan of action to licensing by March 24, 2022

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: During the inspection of the physical facility it was noted that a window in the facility was boarded up with a piece of ply wood. The play wood was placed on the outside of the facility to cover a broken window which broke on November 01, 2021. On the inside of the facility the broken window was covered with a piece of white cardstock taped down with tape. Behind the white cardstock there are jagged pieces of glass which have not have been removed. Children can reach the broken glass. During the Inspection a staff was observed sitting in the area of the broken glass so children cannot touch the broken glass shards, however staff often moves around the classroom and cannot always sit by the broken window to monitor acess to the broken window.
The manager of the facility identified that she arrived at the facility on Nov 01, 2021 to find the broken window. The window glass shards remain in the frame and this presents a critical hazard to children and staff.
Corrective Action(s): Please ensure children do not have access to any hazardous items. Please remove any glass shards and provide a plan for the replacement of the window.
Date to be Corrected: Immediately.

POLICIES AND PROCEDURES: 13060 - CCLR s.56(1)(d) - A licensee must keep current records of each of the following: (d) written policies and procedures that are intended to guide employees in the care and supervision of children.
Observation: During the inspection of the Policies and Procedures it was observed that Active Play and Screen Time Policy was not available. Manager stated that the children go outside and play on the playground daily and that every 4th Friday of the month a movie is watched by the children in the facility. Manager was unable to provide said policies, nor did she know where she might find such policy.
Corrective Action(s): Please ensure all employees have access to all policies and procedures.
Date to be Corrected: March 24, 2022

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 7 random children's files were reviewed and 4 children's files were missing an enrollment date.
Corrective Action(s): Please ensure all children's files are complete.
Date to be Corrected: March 24, 2022

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: During the inspection 7 random children's files were reviewed and 2 were missing a medical practitioner's name and phone number.
Corrective Action(s): Please ensure all children's files are complete.
Date to be Corrected: March 24, 2022

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: During the inspection 7 random children's files were reviewed and 2 were missing a photo of the child.
Corrective Action(s): Please ensure all children's files are complete.
Date to be Corrected: March 24, 2022


Comments

At the inspection dated March 10, 2022 there were 11 children, 1 Support Worker and 2 staff present. At this inspection the above noted contraventions were identified. Actions required by the licensee and actions required the LO included here. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.

The following education/recommendations were provided:
· Promoting Active Play in the program
· Upkeep of the exterior and interior of the facility

The following resources were provided:
· Reportable Incident Bulletin
· Reportable incident forms
· Care Plan Bulletin

Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).

· This report has been written off site. No signature was needed. This report was discussed and emailed to the licensee.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceFollow-up Inspection Required
Due Date
Mar 24, 2022
Approximate Follow Up Date
28 Mar, 2022

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