Promontory Heights Christian Daycare

• OR SUPERVISION

  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. Facility was operating over capacity with 9 children on occasion, although today was in compliance. Facility had relocated to the basement in January and Licensee's own children remain in the upper part of the home and assumed they were no longer part of the group. Further discussed.

  Corrective action. Please provide a corrective action plan to ensure that capacity is no longer exceeded due to enrollment.

  14360 - CCALA s.7(1)(b)(i)
• STAFFING

  A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.

  Observation. The annual emergency drill has not been practiced since February 2025 - further discussed a secondary location for evacuation

  Corrective action. Manager/Licensee said they will practice within the next few weeks and amend the policy to reflect that.

  12200 - CCLR s.22(2)(c)

No violations recorded at this inspection.

• 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 does not include the course of action recommended by health care professionals for a child requiring additional support. Licensee does have a medication form with limited instructions on it.

  Corrective action. Licensee with create a care plan and consult with the parent.

  19220 - CCLR s.58(1)(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 for one volunteer.

  Corrective action. Licensee will collect references for the volunteer

  12152 - CCLR s.19(5)(b)
• STAFFING

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

  Observation. The fire drill for April was not conducted. Licensee said with children's illnesses, it was overlooked.

  Corrective action. Licensee will ensure monthly drills are practiced and recorded. No further response required

  12190 - CCLR s.22(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 (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.

  Observation. Immunization status was not obtained for one volunteer.

  Corrective action. Licensee was unaware of this requirement and will ensure status is available

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

• LICENSING

  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. Licensing observed that care was limited to two rooms of the approved space due to a renovation project in one room in response to flood damage. The Licensee did not submit notification or plans for approval but is currently operating with reduced numbers and therefore meeting space requirements.

  Corrective action. Please ensure when renovations are undertaken, a plan for approval is submitted to Licensing to ensure the health and safety is not impacted. Please submit a plan for completion to Licensing and ensure that enrolment remains limited for the duration of the renovation.

  10030 - CCLR s.10(2)(b)
• STAFFING

  A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.

  Observation. Licensing observed through review of records and discussion with the Licensee that the annual evacuation had not been practiced. This was further discussed.

  Corrective action. Please ensure the annual evacuation drill is practiced to ensure all staff are knowledgable in emergency response.

  12200 - CCLR s.22(2)(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 the Licensee.

  Corrective action. Please ensure immunization status is on file for review.

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

• 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. Fire extinguisher present had no evidence of when it was last serviced/purchased.

  Corrective action. Ensure all fire extinguishers present in the center are serviced annually.

  13020 - CCLR s.22(1)(b)

• EQUIPMENT AND FURNISHINGS

  A licensee must supply equipment, furniture and supplies that are (a) of sturdy and safe construction, easy to clean and free from hazards.

  Observation. Observed 3 shelving units within the living room / main play area. The shelves were not secured / anchored and appeared unsteady posing risk of injury should they fall.

  Corrective action. ensure shelves are secured or relocated to an area where children will not have access as discussed in order to prevent risk of injury.

  11080 - CCLR s.15(1)(a)
• HYGIENE AND COMMUNICABLE DISEASE

  A licensee, other than a licensee who provides a care program described as either Preschool (30 Months to School Age) or Group Child Care (School Age), must have in a community care facility a sturdy surface for changing diapers, located outside the food preparation area, next to (b) a wash basin.

  Observation. A diaper change table located in the hallway entrance area , located also in this area was a child's potty seat which licensee included was for potty training when outdoors. discussed ensuring diaper changing procedures are carried out next to a sink as per section 14 (4) (b) of the CCLR. Reviewed practice of potty use outdoors , children should have access to running water and privacy when toilet training.

  Corrective action. Diaper changing is required to be completed next to a sink however it is acknowledged that sometimes certain areas may be hard to supervision therefore an exemption may be requested to this section of legislation with an approved hygiene plan. Please respond including either relocating the change area to occur next to a sink or by submitting the exemption request.

  15020 - CCLR s.14(4)(b)

• 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 (CORRECTED DURING INSPECTION): A review of 6 children's records noted that 1 was missing the start date.

  Corrective action. Ensure start dates are recorded for each child in care.

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

  A licensee must keep current records for each child showing (a) the information set out in subsection (2), (b) if applicable, the information and agreements set out in subsections (2.1) and (2.2), and (c) the consents referred to in subsection (3).

  Observation. At the time of this inspection authorized pick up information was missing for 1 of 6 records reviewed.

  Corrective action. Ensure authorized pickup information is completed on the registration form for each child in care. Licensee to discuss with the parent and complete the information on the authorization form.

  19060 - CCLR s.57(1)(a)(b)(c)