LICENSING: 10030 - CCLR s.10(2)(b) - Licensees must not make any structural change to a community care facility unless the licensee first (b) receives written approval from the medical health officer.
Observation: Construction is underway to expand the facility. An application to Amend the Existing License was submitted August 17, 2017 to increase the capacity to 80 Group Child Care (School Age) spots. During the last follow-up inspection construction was stopped and the Licensee was instructed to contact Licensing once construction began again. During today's inspection a building permit was observed posted on the outside of Unit 5 which is under construction (BP#17-109566). No record of informing Licensing of construction starting again or approval for changes to be made.
Corrective Action(s): Ensure written approval from Licensing has occurred before structural changes occur to a community care facility.
Date to be Corrected: June 8, 2018
LICENSING: 10120 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: A Healthy and Safety Plan was posted on the wall near the front entrance beside the facility License. This plan was dated September 2017 and was signed by the Licensee. The plan was never approved by Licensing. A copy of the plan was requested from Licensing and delivered by the Licensee the next day. Six items were listed on the H&S Plan.
#1 - four staff available - confirmed during inspection
#2- during construction in unit 5 some rooms will continue to be used - The Green Room was not assessable - not followed
#3 - operational washroom and 4 indoor portable potties - confirmed during inspection - not suitable
#4 - unsafe areas will be marked - not followed
#5 - equipment and tools not accessible - not followed
#6 - child care cleaned daily during construction - not followed - during second inspection facility very well cleaned
Corrective Action(s): Ensure the facility is operated to promote the health and safety of the children in care. An updated Health and Safety Plan must be submitted to Licensing to ensure the health and safety of persons in care is being provided.
Date to be Corrected: June 1, 2018
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: Construction debris, dust and area's under construction were present and assessable to the children in care during the inspection. Unit 5 did not have a door restricting access and tools and equipment were present. Toys and materials designated for the children to use were stored in one space under construction and showed signs of dust accumulation.
Corrective Action(s): Ensure the facility, furniture and equipment are clean and in good repair while children are in attendance. A Health and Safety Plan must be submitted to Licensing.
Date to be Corrected: June 1, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11060 - CCLR s.14(2) - A licensee must have one toilet and wash basin for every 10 children or fewer.
Observation: One toilet and sink were in working order in Unit 7 of the facility. This space was only accessible for one hour or the program and after 4pm not reasonably assessable when the recreational Martial Arts Programs begins. Four indoor Portable Potties were available in a space under construction in Unit 5. These Portable Potties have been on site since September 2017. The Manager relayed that the Portable Potties are sanitized daily by staff and serviced weekly from the rental agency and the records could be provided regarding the maintenance of these units. Hand sanitizer was relayed to be used after each use but was not observed today.
Corrective Action(s): Ensure one sink and toilet is available for every 10 children. The Portable Potties are not an accepted or approved use of toilet. Hand sanitizer is not an accepted or approved use of sink for hand washing purposes. A Health and Safety plan needs to be submitted to Licensing.
Date to be Corrected: June 1, 2018
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 (CORRECTED DURING INSPECTION): The Licensee who is regularly alone with children in care during transportation to and from school has an expired Criminal Record Check from October 2017. The Licensee was unaware that the CRC had expired and had not applied for renewal as of yet.
Corrective Action(s): Ensure all persons employed at a Community Care Facility have valid Criminal Record Checks.
Date to be Corrected: Corrected by Second Day Inspection
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: Four staff files were reviewed and all staff had only one Reference Check in the files. a Minimum of two references are required and the Manager replayed that she was unaware of this. This is a repeat contravention and has been contravened three times before on reports SCLAY-ALURHC, DCAR-A9ESND and IMAY-9RPU45.
Corrective Action(s): Ensure all staff files are complete including character references.
Date to be Corrected: June 4, 2018
STAFFING: 12152 - CCLR s.19(5)(b) - Despite this section, licensee may employ a person as a volunteer who does not provide care to children or supervise children if the licensee or the manager has first met with the person and obtained all of the following (b) character references in respect of the person.
Observation: Two volunteer files were reviewed and they both only had one reference in the files.
Corrective Action(s): Ensure volunteers have complete files including character references.
Date to be Corrected: June 4, 2018
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: Fire and Emergency Drills are conducted and documented on a monthly basis. The Emergency supplies are stored under the stairs and not accessible in the event of an Emergency.
Corrective Action(s): Ensure emergency supplies are assessable to respond to and recover from and emergency evacuation.
Date to be Corrected: June 4, 2018
POLICIES AND PROCEDURES: 13120 - DLSOP Active Play - The Licensee must develop and implement a Screen Use Policy to guide employees in the use of screen time activities.
Observation: A large television monitor is present in the Blue Gym (Unit 7). The Manager stated that sometimes the School-age children will watch movies on Friday's but the monitor was primarily used for Martial Arts Techniques Training Videos. A Screen Use policy is yet to be developed.
Corrective Action(s): Ensure a Screen Use Policy is developed and shared with the families.
Date to be Corrected: June 4, 2018
CARE AND/OR SUPERVISION: 14020 - CCLR s.34(2)(a) - Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.
Observation: The program is presently licensed for a maximum capacity of 20 children. Attendance records were reviewed and on a consistent basis more than 20 children are in attendance. 29 children were in attendance during today's inspection. Six kindergarten aged children were also confirmed to be in attendance on a regular basis when the group numbers exceeded the maximum capacity of 20. The manager relayed that she thought an exemption was approved to offer care to 30 children at one time. No exemption was approved or submitted. This is also considered not exemptible under CCLR's.
This is a repeat contravention from an investigation dated June 2016.
Records reviewed on second day of inspection indicate numbers appear to have been reduced.
Corrective Action(s): Ensure the maximum capacity of the facility is not exceeded and children are divided into groups outlined in Schedule E of the CCLR's. Numbers must be reduced immediately and maintained to be in compliance.
Date to be Corrected: Immediately - May 30, 2018
PROGRAM: 18030 - CCLR s.44(1)(c) - A licensee must provide to children a comprehensive and coordinated program of indoor and outdoor activities that (c) complies with the program standards set out in Schedule G.
Observation: The group of children were observed engaged in Martial Arts Training and snack. Toys, resources and materials were stored in a room under construction and showed signs of dust and debris from construction. The Manager relayed that the resources are pulled out daily for the children to engage with. This was not observed today.
Corrective Action(s): Ensure programming and materials are accessible and provided to the children in care as outlined in Schedule G of the CCLR's
Date to be Corrected: June 4, 2018
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 (CORRECTED DURING INSPECTION): Five children's files were reviewed and one child did not have a Medical Service Plan number noted. The Manager relayed that this was an error and would be resolved at the end of the day.
Corrective Action(s): Ensure all children's files are complete including Care Card numbers for each child.
Date to be Corrected:
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