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: During inspection following was observed:
- Several lower areas of the walls at the child's level, the paint has begun to peel, starting to expose the drywall beneath it, and a few sections of the walls had stains and scuff marks.
- One wall had a ½ inch hole in the wall at the child’s level
- Some Parts of the carpet in the play areas are stained and are in need of cleaning. Manager explained that the carpets are cleaned every two months but the stains are difficult to get rid of.
- Duct tape on the diaper change pad is starting to show signs of wear and tear
Corrective Action(s): Please that the carpets and the walls in the facility are clean and in good repair.
Date to be Corrected:
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: One staff file does not have a CRC completed through the criminal record review agency in Victoria. That staff person currently has a clear criminal record check from the RCMP in their file.
Corrective Action(s): Please ensure that staff have valid criminal record checks through criminal records review program in Victoria; before they start employment.
Date to be Corrected:
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 (CORRECTED DURING INSPECTION): Licensing reviewed one staff file and evidence of references being checked was not available Manager explained that she did call the references but did not make a note of it. This was corrected during inspection.
Corrective Action(s): Ensure that character references are obtained and also verified for each employee before they start employment.
Date to be Corrected:
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 (CORRECTED DURING INSPECTION): Immunization status was not obtained for one staff.
Corrective Action(s): Please ensure there is evidence that the staff has complied with the Province's immunization and tuberculosis control programs.
Date to be Corrected:
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 (CORRECTED DURING INSPECTION): During morning snack routine Licensing observed that the Manager did not wash children hands before eating. When Licensing brought this to the Manager's attention, she washed their hands immediately. Later, on another occasion Licensing observed the staff did not wash a child's hands after eating and was send to play with other children.Licensing pointed this out to the Manager and she asked the staff to wash that child's hands. Licensing discussed with the Manager the importance of washing children's hands before and after eating routines.
Corrective Action(s): Please make sure that all children wash their hands before and after eating routines to help prevent the spread of infection and to reduce the risk of accidental food allergen exposure.
Date to be Corrected: 9 November 2023
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 (CORRECTED DURING INSPECTION): One child's file was missing date of enrollment. This is repeat contravention from routine inspection SMIA-BXGUT7 dated 21 January 2021.
Corrective Action(s): Please ensure that the date of enrollment is noted in the children's file when they begin enrollment.
Date to be Corrected:
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: One child has an epipen, but no care plan has been developed in consultation with the parent or any other person the parent has requested. The manager was unable to describe what actions would be required if the child had a reaction that required the use of the epi pen.
Corrective Action(s): Please ensure that a care plan for the use of an epipen is developed in consultation with the parent of the child requiring support and any other person requested by the parent.
Date to be Corrected: 14 November 2023
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