Yu's Montessori School in Burnaby

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. Licensing observed the following in the napping area: - Two mattress covers were flaking off with the cotten/fabric exposed, making it difficult to sanitize - One of the mattress covers appears to have moldy spots.

Corrective action. Manager said that the mattress covers will be replaced by the new ones that are kept in the storage.

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. Licensing reviewed staff files and noted that one file is missing character references. Manager explained that the record is kept in the computer but unable to show Licensing during inspection.

Corrective action. Manager will ensure that all the staff files are complete

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. Licensing reviewed staff files and noted that immunization status was not obtained for one staff. This is repeated contravention to inspection report #CLAN-DBNRW7.

Corrective action. Manager will ensure that all the staff files are complete

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. Licensing reviewed staff files and noted that one file was missing evidence of the certificate being validated. This is a repeated contravention to inspection report #MZIN-CBENLQ

Corrective action. Manager will ensure that all staff files are complete

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

Observation. Licensing observed the following during the inspection: -Loose cords -Rust underneath paint chips on the slide in the outdoor play area. Please provide active supervision until this is corrected. (Please correct by February 5, 2025)

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

Observation. Licensing observed the fire extinguisher. The service date was noted on the service tag as August 17, 2024. The fire extinguisher was within the area of being fully charged.

Corrective action. In discussion the Manager stated the pastor is responsible for servicing the fire extinguishers. Licensing discussed putting a system in place to check fire extinguishers.

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. The staff records were reviewed. Immunization status was not obtained for two employees.

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. During the inspection Licensing observed the staff records. One staff record was missing a site specific criminal record check

A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager. Observation (CORRECTED DURING INSPECTION): Licensing observed that the community care facility licence and the name of the manager were not displayed on-site.

Corrective action. Ensure that the community care facility licence and the name of the manager are always displayed on-site in a prominent place.

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. Licensing observed that one staff's CRC was expired.

Corrective action. Ensure that staff files are updated and that the CRC is attained from the review board.

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. Licensing observed peeling paint and wood exposure in the window frames and exterior facade outside at the outdoor play area. The manager said that this has been communicated to the landlord of the building. This item was previously coded on facility inspection report #MZIN-CBENLQ on Feb. 04, 2022.

Corrective action. Ensure that the facility is in good repair particularly in specific areas such as the outdoor space, where children are regularly present.

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 (CORRECTED DURING INSPECTION): Although the facility completed the drill, Licensing observed that the yearly emergency drill for 2022 was not recorded.

Corrective action. Ensure that the yearly emergency drill is recorded.

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): During inspection Licensing observed the following: - The door leading into the kitchen was left open and therefore, cleaning supplies located under the kitchen sink were accessible to children. Note: This item was previously coded on facility inspection report #SMOY-BRZLT8. - In the nap room area, a container with hand sanitizer was placed on top of a plastic cabinet, which was accessible to children.

Corrective action. Ensure children do not have access to any substances that may be hazardous to their health or safety.

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. Licensing observed the following: - Peeling paint located in the door frames, window frames and exterior fascade of the outdoor play area which is accessible to children - Peeling paint on the wall of the hallway indoors which is accessible to children

Corrective action. Ensure the facility is in good repair while children are in attendance

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

Observation. Licensing observed the following: - The edges of the area rug are curled which can be a tripping hazard. Note: This item was previously coded on facility inspection report #KSEY-BB3P7Y. - In the nap room area, a plastic basket which contained items was on the very top of a shelving unit attached to the wall. Due to the fact that the shelf where the basket was stored did not have a lip, in an event of an earthquake, this could potentially fall on an individual. This was corrected during inspection, as the basket was moved to a place where it is no longer a potential hazard.

Corrective action. Ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.

A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility. Observation (CORRECTED DURING INSPECTION): Licensing checked the children's files and observed that 2 children did not have their date of enrolment noted on file.

Corrective action. Ensure the date of enrolment is noted in the children's files

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. Licensing reviewed staff files and noted that 3 files were missing evidence of the certificates being validated. During the inspection, Licensing showed the procedure and the website for validating the certificates. Note: This item was previously coded on facility inspection report #SMOY-BRZLT8.

Corrective action. Ensure that all staff certificates are validated which needs to be included on file

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

Observation. There is a water dispenser in the main activity room that dispenses both hot and cold water. The Licensee said the hot water is about the same temperature as boiling water as staff use the water for the hot beverages. There is a corrugated board placed across the dispenser however children still have easy access to the dispensers. There is the potential for a child to receive a burn or be scalded from the hot water. NOTE: this item has been previously coded on facility inspection report #KSEY-A2ENPM dated September 16, 2015.

Corrective action. The Licensee is considering installing a panel/door with a lock to be placed in front of the machine.

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

Observation. 1) on July 23, 2020 Licensing saw animal feces in the resilient surfacing of the fenced in play area. The Director of Licensing Safe Play Spaces require staff to conduct a daily check of the playground and maintain a record. 2) the landlord has replaced the perimeter fencing of the play area. The Licensee said the fence height was previously approximately 6' high and Licensing measured the new fence and it is approximately 3'6" high. The grade outside the fence is approximately 12' and a fence height should be, at a minimum 6' to mitigate risk for children. Licensing took 2 photographs of the fence and provided the Licensee with copies with this report.

Corrective action. 1) Ensure staff conduct a daily safety check of the play space for garbage, broken glass, animal feces and other hazardous items and maintain a log of the inspections, maintenance and repairs. 2) The Licensee and Manager discussed the fence height with Licensing. The Licensee will need to address the issue of the fence height by August 31, 2020 and have Licensing approve of any changes. The facility will be closed for the month of August 2020 and in the meantime staff will need to practice active supervision until the end July 2020.

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. Licensing observed rust in the following areas: - boys washroom; a lower portion of a large painted pipe has areas of rust. - outdoor swing set with 2 swings; the chains on both swings are completely rusted. - main entry wooden gate; the latch is completely rusted and the hinges are showing signs of rust. Rust is a potential health hazard.

Corrective action. Repair or replace the above noted items to remove the rust.

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. The kitchen area has doors and during both days the Licensing was inspecting the doors leading into the kitchen were left open. Licensing observed cleaning supplies including sanitizing products and staff purses accessible to children. The Manager and the Licensee both indicated that children know they are not permitted in the kitchen.

Corrective action. All hazardous items must be kept out of reach of children to prevent a child from inadvertently being injured or poisoned. While staff supervision can be a portion of the plan to prevent children from accessing items there remains the potential for a child to access items without a staff being aware.

A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.

Observation. Licensing noted the name of the facility Manager is not posted.

Corrective action. Ensure the name of the Manager is posted for individuals to identify who is in charge.

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. The Manager informed Licensing the perimeter fencing was replaced while the facility was closed during the months of April and May 2020. The City of Burnaby required the landlord to replace the fence and the Licensee was unaware of the changes until they reopened the facility.

Corrective action. Ensure Licensing is informed of any structural changes as Licensing needs to approve the changes.

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. In the facility's outdoor play area there is a slide and a swing set with 2 swings. The Manager and Licensee said that staff bring out a bucket of toys for children to use outdoors. Upon review of the items in the bucket and in discussion with the Manager and Licensee they are not meeting the requirements for gross motor activities as per Schedule G. In addition to the play area with the above noted fixed equipment there is another outdoor play area as per the facility's exemption for outdoor play area. The one play area is only sufficient for 10 children and the secondary play area must be made accessible to children when there are over 10 children in care. This area may be a place where staff can provide additional gross motor (large motor) activities.

Corrective action. Licensing is requesting the Manager and/or Licensee submit a written action plan as to how staff will amend their outdoor activities to meet the legislative requirements. NOTE: children must have daily outdoor play for a minimum of 60 minutes per day.

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 licensee using a system established and maintained by the director of the early childhood educator registry,

Observation. Licensing reviewed staff files and noted of the three files reviewed two files were missing evidence that the Manager and/or Licensee verified the individual's early childhood educator's certificate. NOTE: this item was previously coded on facility inspection report #KSEY-AZZNC5.

Corrective action. Prior to individuals commencing work the Manager/Licensee must ensure that staff files are complete.

A licensee must not employ a person in a community care facility unless the licensee is satisfied, based on the information available to the licensee under subsection (1) and the licensee's or, in the case of an employee who is not the manager, the manager's own observations on meeting the person, that the person (b) has the personality, ability and temperament necessary to manage or work with children.

Observation. Upon review of four staff files Licensing noted that all files were missing verification of the individual's references. NOTE: this item was previously contravened on facility inspection report #KSEY-AXXNC5 dated April 18, 2018.

Corrective action. The Manager and/or Licensee will need to develop and implement a system to demonstrate that they have verified staff references.