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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MGIL-CLMUTH

FACILITY NAME
CEFA Early Learning Surrey - Nordel
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
LSEO-B5UTZG
FACILITY ADDRESS
200 - 8820 120th St
FACILITY PHONE
(778) 368-7608
CITY
Surrey
POSTAL CODE
V3V 0C9
MANAGER
Xianjing Jin

INSPECTION DATE
November 29, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.5
ARRIVAL
11:15 AM
DEPARTURE
12:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 (DLSP). 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
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: In a room that is only licensed for a capacity of 4 children, there were 6 children present. They were of the same age group and attending the same service type, however, they were over the maximum allowable capacity according to the license.
Corrective Action(s): Ensure to remain within the maximum allowable capacity at all times as per the license issued.
Date to be Corrected: Nov 29, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11010 - CCLR s.13(1) - A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.
Observation: - the bedding for napping was touching one another. In some instances, the cot legs were also touching the bedding

- there were toys stored in a crib and playpen in the infant room and these had bedding in them ready for a child to sleep and were being used currently

- a mop and brooms were stored in the washroom accessible to children
Corrective Action(s): Ensure a healthy and hygenic environment at all times.
Date to be Corrected: Nov 29, 2022

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: The drywall is chipping and exposed on the walls in some of the rooms
Corrective Action(s): Ensure the facility is in good repair at all times
Date to be Corrected: Dec 5, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11160 - CCLR s.16(3)(a) - A licensee must ensure that the entire outdoor play area is (a) enclosed in a manner that is suitable for the age and development of children, and will ensure that children are free of harm.
Observation: The 2 gates entering each of the play yards have a large gap between the gate and the pole; this could pose to be an entrapment issue.
Corrective Action(s): Ensure the gap between the gate and pole is not more than 3" and does not pose a risk to the chidren in care
Date to be Corrected: Dec 5, 2022

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 had a criminal record check that was not site specific. Another staff did not have a criminal record check; this staff cannot work alone with the children including toileting and diapering.
Corrective Action(s): Ensure all staff have valid criminal record checks that are site specific and done through the criminal records review program.
Date to be Corrected: Nov 30, 2022

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: 1 staff file was missing references
Corrective Action(s): Ensure to have 2 references on file for each staff
Date to be Corrected: Dec 5, 2022

STAFFING: 12060 - CCLR s.19(1)(c) - 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: (c) a record of the person's work history.
Observation: A record of the person's work history was not obtained for one or more employees.
Corrective Action(s): Ensure to have this information on file for each staff.
Date to be Corrected: Dec 5, 2022

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: Immunization status was not obtained for one or more employees.
Corrective Action(s): Ensure to have this information on file for each staff
Date to be Corrected: Dec 5, 2022

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: Evidence of ECE certificate validation was not on file for 1 staff
Corrective Action(s): Ensure to have this information on file
Date to be Corrected: Dec 5, 2022

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: A minimum of two character references were not obtained for one or more volunteers.
Corrective Action(s): Ensure to have this information on file
Date to be Corrected: Dec 5, 2022

STAFFING: 12153 - CCLR s.19(5)(c) - 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 (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Immunization status was not obtained for one or more volunteers.
Corrective Action(s): Ensure to have this information on file
Date to be Corrected: Dec 5, 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: A random sample of children's files indicated one was missing the name and number of a doctor or walk in clinic
Corrective Action(s): Ensure to have this information on file
Date to be Corrected: Dec 5, 2022


Comments

At the inspection dated Nov 29, 2022 there were 51 children and 12 staff present throughout the entire facility in all of the programs operating. At this inspection, the above noted contraventions were identified. As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided.

The following was discussed:
- installing some form of privacy in the first stall of the washroom in the 3-5 room and any other stalls that this might be a concern
- references for staff

Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR). This report was reviewed with the Manager and a copy will be emailed.

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
Dec 05, 2022

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