Three Bears Centre

• RECORDS AND REPORTING

  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. Ten children's files were reviewed. Immunization status was missing in one file

  Corrective action. Manager said she will ensure immunization status is available in all files

  19070 - CCLR s.57(2)(a)
• STAFFING

  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. 4 staff files were reviewed. A resume was missing from one file.

  Corrective action. The manager said she will ensure that a resume will be available for all staff

  12060 - CCLR s.19(1)(c)
• STAFFING

  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. Four staff files were reviewed. Immunization status was not available in one file

  Corrective action. The manager said she will ensure the immunization status is available in all files

  12090 - CCLR s.19(1)(f)

No violations recorded at this inspection.

• EQUIPMENT AND FURNISHINGS

  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. A large panel of fencing in the outdoor play area is not secure and is unstable. The manager stated the fence has been like this for two weeks.

  Corrective action. The manager will ensure that repairs are made to the fence and that staff will supervise children to ensure they do not touch the unstable areas of fencing.

  11020 - CCLR s.13(2)
• POLICIES AND PROCEDURES

  A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.

  Observation. There is an inadequate amount of supplies in the emergency kit for all children for up to 72 hours.

  Corrective action. The manager will ensure that there are enough supplies for all children for 72 hours.

  13020 - CCLR s.22(1)(b)
• RECORDS AND REPORTING

  A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (c) the resources to be made available to the child requiring extra support by the licensee, including (i) any adaptation of the community care facility necessary to ensure the child's safety or comfort.

  Observation. Medication required by a child requiring extra support had expired.

  Corrective action. The manager will ensure all medications have a current expiry date.

  19230 - CCLR s.58(1)(c)(i)
• RECORDS AND REPORTING

  The licensee must (b) review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.

  Observation. A care plan for one child was not reviewed annually with the parent or any person requested to by the parent.

  Corrective action. The manager will ensure the care plan is reviewed with the parent.

  19260 - CCLR s.58(2)(b)
• STAFFING

  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 and verified for a volunteers.

  Corrective action. The manager will ensure a minimum of two references are obtained and verified for the volunteer.

  12152 - CCLR s.19(5)(b)
• STAFFING

  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 a volunteers.

  Corrective action. The manager will ensure immunization status is obtained for the volunteer.

  12153 - CCLR s.19(5)(c)

• EQUIPMENT AND FURNISHINGS

  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 (CORRECTED DURING INSPECTION): Medication was being stored in a cubby and was accessible to children.

  Corrective action. The medication was removed during this inspection.

  11200 - CCLR s.17
• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.

  Observation. Mr Clean is used to clean the facility. This product does disinfects but does not sanitize. This is repeat noncompliance and was noted on routine inspection #WBET-CERQ8Z.

  Corrective action. Please ensure a product that sanitizes is used in the facility.

  11010 - CCLR s.13(1)
• RECORDS AND REPORTING

  A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.

  Observation. Files for 10 children were reviewed. A start date was missing for two files.

  Corrective action. Please ensure a start date is available for all children.

  19080 - CCLR s.57(2)(b)
• RECORDS AND REPORTING

  A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (a) the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.

  Observation. A care plan is not available for a child requiring extra support.

  Corrective action. Please ensure a care plan is available for all children who require extra support.

  19210 - CCLR s.58(1)(a)
• RECORDS AND REPORTING

  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. Files for 10 children were reviewed. An emergency contact person was not available in one file and contact information for a doctor or medical clinic was not available in two files.

  Corrective action. Please ensure all files contain the required information.

  19100 - CCLR s.57(2)(d)
• STAFFING

  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.

  Corrective action. All employees (including substitute staff) need to have a resume on file.

  12060 - CCLR s.19(1)(c)
• STAFFING

  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 employee.

  Corrective action. All staff (including substitutes) must have immunization status on file.

  12090 - CCLR s.19(1)(f)
• STAFFING

  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. An ECE certificate for one staff has not been validated.

  Corrective action. Please ensure all ECE certificates are validated.

  12140 - CCLR s.19(4)(a)
• STAFFING

  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. Evidence of references being checked is not available and one staff has one reference instead of the required two.

  Corrective action. Please ensure all staff have a minimum of two references (the manger needs three) and that evidence of the references being checked is available.

  12050 - CCLR s.19(1)(b)
• STAFFING

  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. A criminal record check for one staff was not obtained through the sharing program of the Criminal Record Review Agency (CCRA).

  Corrective action. If a criminal record check is not site specific a copy must be obtained through the sharing program of the CRRA.

  12040 - CCLR s.19(1)(a)

No violations recorded at this inspection.

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.

  Observation. Mr Clean is being used in the facility. Although this product disinfects it does not sanitize.

  Corrective action. Please ensure a sanitizing solution is used to clean the facility.

  11010 - CCLR s.13(1)
• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that any heated water accessible to children is heated to no more than 49° Celsius.

  Observation. Washrooms in the upper floor of the church are temporarily being used. Hot water in these washrooms was measured at 53c.

  Corrective action. Please ensure children do not have access to water hotter than 49c.

  11230 - CCLR s.47
• LICENSING

  Applicants for licences and licensees must notify a medical health officer immediately of any change in the information provided under section 9.

  Observation. During this inspection staff informed the Licensing Officer that pipes in the children's bathroom had burst causing a flood and making the bathroom unusable. This took place in April 2022 and repairs have been started but not completed. Bathrooms in an unlicensed area of the ground floor and at times bathrooms on the upper floor of the church are currently being used. The Licensee had not informed Licensing that the facility bathrooms were not available for use.

  Corrective action. A licensee must inform Licensing of any significant changes to the operation of a facility. A health and safety plan outlining how the toileting and hand washing routines are being implemented until repairs to the facility bathrooms are completed must be submitted to the Licensing Officer and the Licensee needs to give their assurance that any changes to the information submitted in the application for license are reported to Licensing.

  10010 - CCLR s.10(1)
• POLICIES AND PROCEDURES

  A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].

  Observation. Fire drills are not being recorded.

  Corrective action. Please ensure all fire and emergency drills are recorded.

  13050 - CCLR s.56(1)(c)
• RECORDS AND REPORTING

  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. Files for 10 children were reviewed. A medical insurance number was not available in 3 files and immunization status was not available in 1 file.

  Corrective action. Please ensure all children's files contain a medical insurance number and immunization status.

  19070 - CCLR s.57(2)(a)
• RECORDS AND REPORTING

  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. Files for 10 children were reviewed. The name and contact information for a doctor/medical clinic and an emergency contact person was not available in 3 files.

  Corrective action. Please ensure contact information for a doctor/medical clinic and an emergency contact person is available for all children.

  19100 - CCLR s.57(2)(d)
• STAFFING

  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/ECEA certificates bein validated was not available in 3 staff files.

  Corrective action. Please ensure all ECE/ECEA certificates are validated through the early childhood educator registry.

  12140 - CCLR s.19(4)(a)
• STAFFING

  A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.

  Observation. A fire drill has not been conducted since February 2022.

  Corrective action. Please ensure a monthly fire drill is conducted.

  12190 - CCLR s.22(2)(b)

• EQUIPMENT AND FURNISHINGS

  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. Tape that has been used to repair mats is loose and areas of foam are exposed on some bed mats.

  Corrective action. Please ensure that foam is not exposed on bed mats.

  11020 - CCLR s.13(2)
• RECORDS AND REPORTING

  A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (b) the courses of action recommended by health care professionals to address the needs of the child requiring extra support.

  Observation. A care plan including the course of action recommended by health care professionals for a child requiring additional support is not available for two children.

  Corrective action. Please ensure a care plan is available for all children requiring extra support.

  19220 - CCLR s.58(1)(b)
• STAFFING

  The licensee must not permit a person over the age of 12 to be ordinarily present on the premises of a community care facility while children are present, unless the person is of good character and the licensee has obtained a criminal record check for that person.

  Observation. A criminal record check for two persons are not available. The manager stated these persons are employed by an outside agency and a family and not the facility.

  Corrective action. Please ensure all persons ordinarily present who are not employed by the licensee have evidence of a valid criminal record check.

  12160 - CCLR s.20(1)

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.

  Observation. Areas of foam are exposed on some sleep mats making the mats difficult to sanitize.

  Corrective action. Please ensure foam is not exposed on sleep mats. The use of duct tape to cover the foam was discussed with the manager.

  11190 - CCLR s.16(4)(b)
• RECORDS AND REPORTING

  A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (a) the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.

  Observation. One child has a food allergy and no care plan is available.

  Corrective action. Please ensure a care plan is available for any child that has a food allergy.

  19210 - CCLR s.58(1)(a)
• RECORDS AND REPORTING

  The licensee must (b) review the care plan at least once each year with a parent of the child requiring extra support and any person requested by the parent.

  Observation. One care plan has not been reviewed since 2018.

  Corrective action. Please ensure all are plans are reviewed a minimum of once every 12 months

  19260 - CCLR s.58(2)(b)
• RECORDS AND REPORTING

  A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (c) the resources to be made available to the child requiring extra support by the licensee, including (i) any adaptation of the community care facility necessary to ensure the child's safety or comfort.

  Observation. Medication required by one child requiring extra support expired in March 2021.

  Corrective action. Please ensure all medications have a current expiry date.

  19230 - CCLR s.58(1)(c)(i)
• STAFFING

  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. The manager was unable to locate the file and proof of immunization for one volunteer was not available during this inspection.

  Corrective action. Please ensure proof of immunization is available for all volunteers.

  12153 - CCLR s.19(5)(c)
• STAFFING

  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. References were not available for two volunteers.

  Corrective action. Please make sure references are available and have been checked for all volunteers.

  12152 - CCLR s.19(5)(b)
• STAFFING

  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 (a) a criminal record check for the person.

  Observation. The manager was unable to locate the file and a criminal record check was not available for one volunteer.

  Corrective action. Please ensure a criminal record check is available for all volunteers.

  12151 - CCLR s.19(5)(a)