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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
ONIR-C7QSUD

FACILITY NAME
CEFA South Delta
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
MLAO-AN5PJN
FACILITY ADDRESS
202 - 4890 Canoe Pass Way
FACILITY PHONE
(778) 322-3629
CITY
Tsawwassen
POSTAL CODE
V4M 0B1
MANAGER
Yat Lok Nian Chan

INSPECTION DATE
October 12, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:45 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
59

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: During the inspection the following was observed:
- the wall in one of the classrooms was chipped and dry wall was exposed.
- the change mat in one of the toddler classrooms had a large rip in it and the sponge was exposed, making it difficult to clean.
- the electrical plugs in two classrooms were not covered with plug coverings.
Corrective Action(s): Please ensure the facility is in clean and good repair.
Date to be Corrected: October 26, 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: During the inspection of 6 classrooms it was observed that every classrooms kept the cleaning bottle (bleach bottle) on the countertop in the bathroom. The bottle can easily be accessed by children.
Corrective Action(s): Please ensure that children do not have access to any hazardous substances.
Date to be Corrected: October 26, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11220 - CCLR s.23(2) - A licensee must have first aid kits that are readily accessible to all employees, including while care is provided off the community care facility premises.
Observation: A review of two first aid bags showed that the first aid kits did not have sufficient gloves and Band-aids.
Corrective Action(s): Please ensure the first aid is stocked with supplies and readily accessible to staff.
Date to be Corrected: October 26, 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: During the inspection 6 staff files were reviewed and 2 staff references were not checked.
Corrective Action(s): Please ensure you verify the references for all staff.
Date to be Corrected: October 26, 2021

STAFFING: 12140 - CCLR s.19(4)(a) - A licensee must not employ a person in a community care facility as (a) an educator or an assistant unless the person holds a certificate issued under Division 2 [Employee Qualifications], which must be verified by the system maintained by the early childhood educator registry. (Educator or assistant certificate validation)
Observation: During the inspection 6 staff files were reviewed and 2 staff were missing validation of ECE certificate.
Corrective Action(s): Please ensure you verify all ECE certificates.
Date to be Corrected: October 26, 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: During the inspection a total of 14 children's files were reviewed and 2 children did not have a record of immunization status.
Corrective Action(s): Please ensure all children's files are complete.
Date to be Corrected: October 26, 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: During the inspection a total of 14 children's files was reviewed and 2 children were missing an emergency contact person.
Corrective Action(s): Please ensure all children's files are complete.
Date to be Corrected: October 26, 2021


Comments

At the inspection dated Oct 12, 2021 there were 59 children, 14 staff the owner 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:
· Care plans to be reviewed anually.
· Temporary Placements and Exemptions
· Storage in bathrooms
· Electronic attendance

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


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 compliance, Provide a written response to LicensingNo action required
Due Date
Oct 26, 2021

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