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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
IMAY-AENMW8
FACILITY NAME
KinderHeart Montessori - Osprey		SERVICE TYPES
303 Preschool (30 months to school age)
305 Group Child Care (School Age)
FACILITY LICENSE #
JDUT-7FJR58
FACILITY ADDRESS
101, 102, 103 & 104 - 10957 Barnston View Rd		FACILITY PHONE
(604) 465-8585
CITY
Pitt Meadows		POSTAL CODE
V3Y 0B6		MANAGER
Saskia Nicholls
INSPECTION DATE
October 12, 2016		ADDITIONAL INSP. DATE (multi-day)
October 13, 2016		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:45 AM		DEPARTURE
12:15 PM		ARRIVAL
10:30 AM		DEPARTURE
11:30 AM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at www.fraserhealth.ca/health-info/health-topics/child-care/ for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)
Contraventions
Previous Inspection - Contraventions observed on FIR #IMAY-9XYNTX have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
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: Two staff were missing current Criminal Record Clearances (CRC). 1 had expired September 27, 2016 and 1 had completed the authorization form in August 2016, however, the clearance letter had not yet been received.
Corrective Action(s): Ensure current CRC's are on file for all staff.
Date to be Corrected: October 20, 2016.

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): One staff record reviewed was missing immunization status.
Corrective Action(s): Corrected while Licensing was on site.
Date to be Corrected:

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: At the time of this inspection, a policy regarding how allegations of abuse would be managed in situations where it is alleged that staff person abused a child in care was not found. This was also noted in the previous inspection.
Corrective Action(s): Ensure staff are aware of Kinderheart's policy regarding abuse allegations.
Date to be Corrected: October 20, 2016

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: At the time of this inspection, 1 of the 16 children's records reviewed was missing immunization status.
Corrective Action(s): Ensure immunization status is on file for each child attending.
Date to be Corrected: October 20, 2016
Comments

Day 1 - Routine inspection was completed for the Group under 36 months program (Infant/Toddler program (I\T program) and Group 30 months to School-Age (3-5 programs). A random sampling of 16 children's records was completed - 10 on the I/T side and 6 on the 3-5 side.

As discussed all areas of the registration forms should be completed to indicate the status of the information that is being requested as opposed to leaving the areas blank - e.g. special instruction. In addition, the information should be consistent with other areas where this information is documented - i.e. the registration form and tracking form information should match.
A review of some of the immunization declaration forms indicated that the bottom area for the employer to complete, the majority of the time is left blank.
One of the children's records indicated sole custody of a child. Manager to follow-up with the custodial parent to determine as to whether there is a court order restricting access by the non-custodial parent as the registering parent had indicated that the non-custodial parent is not authorized to pick up the child.

5 staff files were reviewed and found complete on the I/T side. 4 staff files were reviewed on the 3-5 side. One staff record was missing immunization status and this information was corrected while Licensing was on site. 1 staff's criminal record clearance (CRC) had expired and 1 staff's CRC had not been received. The Manager advised that the authorization for criminal record clearance had been completed in August 2016, however, the CRC letter had not yet been received. 1 staff was missing a medical clearance, however, it is noted that the section of the Child Care Licensing Regulation (CCLR) requiring staff to have medical clearances has just been recently repealed. As such, medical clearances are no longer a requirement under the CCLR. It is recommended that Licensee's develop their own policy's regarding requirements for medical clearances from a business practice.
Day 2 - Routine inspection was completed for the Preschool. 8 children’s records were reviewed and found complete. 2 Staff records were reviewed and found complete.
The following resources were provided:

Live 5210 Folder (x4)
Child Care LInks Checklist (x4).

Licensing would like to thank you for your time during this inspection and looks forward to a continued working relationship with Kinderheart Osprey. Written response to this report is expected by October 20, 2016.
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
Oct 20, 2016
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.