Royal Academy

• 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. A child's file had a doctor/clinic name listed, though there was no phone number on file.

  Corrective action. Ensure that the file is complete.

  19100 - CCLR s.57(2)(d)

• 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. Licensing observed the following: - In one classroom, liquid cleaning detergent (two containers) were under the sink which could potentially be accessible to children when the cabinet door is opened. - One children's bathroom had some water in a mop bin, and another children's bathroom had some water and liquid cleaning detergent in a mop bin. (This was corrected during the inspection).

  Corrective action. Ensure children do not have access to substances that may be hazardous to their health or safety while in care at the facility.

  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. The following were observed: - Stacked beddings were touching while stored in classrooms - In one classroom, a staff's personal belongings (purse and jacket) were placed on a chair accessible to children. This is a repeat contravention on routine inspection report #CGEE-CHDR5D on 17-Aug-2022.

  Corrective action. Ensure a healthy and safe environment at the facility is provided at all times.

  11010 - CCLR s.13(1)
• 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. Three care plans which were last reviewed in 2023, were not reviewed annually with the parent or any person requested to by the parent. This is a repeat contravention on routine inspection report #CGEE-CBAU83 on 21-Jan-2022.

  Corrective action. Care plans are to be reviewed, signed and dated annually by parents, in the event that there are any changes to children's needs.

  19260 - CCLR s.58(2)(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. Repeat violation from FIR #CGEE-B84TRM (04/Jan/2019). CCFL reviewed 16 children's records, in which 2 lacked complete start dates.

  Corrective action. All requirements of s.57 must be obtained by children's 1st day of care.

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

  A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure. Observation (CORRECTED DURING INSPECTION): Repeat violation from FIR #CGEE: - B84TRM (04/Jan/2019) - CBAU83 (21/Jan/2022) - CHDR5D (17/Aug/2022) A MACC child's arrival time was undocumented.

  19090 - CCLR s.57(2)(c)
• STAFFING

  Immediately after a person who was the subject of a character reference is no longer employed by or ordinarily present at the community care facility, a licensee must return all character references to the person, or destroy the character references.

  Observation. A former employee's 3 references remained in her file.

  Corrective action. Former employees' references must be returned or destroyed after their last day of employment.

  12470 - CCLR s.60(4)

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. In GCC (< 36m)'s outdoor play space, a few rubber tiles have separated from 1 another, creating a trip & fall hazard.

  Corrective action. The gaps must be eliminated to prevent children from tripping & falling.

  11020 - CCLR s.13(2)
• 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. In GCC (30m–SA; Room 1), employees' purses were on the ground near the window.

  Corrective action. Employees' personal items must be inaccessible to children, in case there are hazardous items inside.

  11010 - CCLR s.13(1)
• 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. The fire extinguisher in: • GCC (30m–SA; Room 1) required servicing in 2020 • the entrance has no service tag

  Corrective action. The fire extinguisher in: • GCC (30m–SA; Room 1) requires servicing • the entrance requires servicing OR evidence that it has been serviced in the last 12 months

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

  A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure. Observation (CORRECTED DURING INSPECTION): On today's GCC (< 36m; Room 3) attendance sheet, an absent child & a present child were unaccounted for.

  19090 - CCLR s.57(2)(c)
• RECORDS AND REPORTING

  A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee. Observation (CORRECTED DURING INSPECTION): A reportable incident form (RIF) from 05/Jul/2021 re. "other injury" was in the affected child's file. The incident was never reported to CCFL.

  Corrective action. If a child requires emergency care by a medical/nurse practitioner OR transfer to a hospital as a result of choking, falling, food poisoning, medication error, other injury, or unexpected illness, CCFL must be notified within 24 hours after the emergency care or hospital transfer occurred. CCFL took the RIF's yellow copy for data entry.

  19030 - CCLR s.55(2)(a)
• STAFFING

  A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements].

  Observation. An employee's CRC expired on 2022/07/24. A new CRC has been applied for, but has yet to arrive.

  Corrective action. Until her new CRC arrives, she cannot work alone w/ children or assist w/ diapering/toileting.

  12430 - CCLR s.56(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. An employee's CRC share has been applied for, but has yet to arrive.

  Corrective action. Until her CRC share arrives, she cannot work alone w/ children or assist w/ diapering/toileting.

  12040 - CCLR s.19(1)(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. An employee's work history was missing.

  Corrective action. All requirements of s. 19(1) are required by employees' 1st day of employment.

  12060 - CCLR s.19(1)(c)

• 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. High, wall-mounted open shelving units displayed heavy items.

  Corrective action. These shelving units must not display heavy items. In the event of a substantial earthquake, these items could fall & cause injury to a child.

  11080 - CCLR s.15(1)(a)
• LICENSING

  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. The previous manager's name was still posted by the front door.

  Corrective action. The current manager's name must be posted conspicuously.

  10050 - CCLR s.11(1)
• RECORDS AND REPORTING

  A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure. Observation (CORRECTED DURING INSPECTION): A child in Room 4 (GCC < 36 mos]) wasn't signed out upon early pick-up today.

  19090 - CCLR s.57(2)(c)
• 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. 2 children's care plans were last signed & dated by their parent over a year ago.

  Corrective action. Care plans must be reviewed, signed, & dated annually by parents, in the event that there are any changes to their child's extra support needs.

  19260 - CCLR s.58(2)(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. 4 employees' CRCs were addressed to a former organization. 1 employee lacked a CRC.

  Corrective action. These 5 employees can't work alone w/ children or assist w/ toiletting/diapering until their CRC (share) has arrived.

  12040 - CCLR s.19(1)(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: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.

  Observation. An employee lacked her immunization status in her file.

  Corrective action. All requirements of s. 19(1) must be obtained by employees' 1st day of employment.

  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 employee's most recent certificate hadn't been validated.

  Corrective action. Certificate validation ( https://earlychildhoodeducator.gov.bc.ca/Public/CertAndRenewal/Certificate_Validation.aspx ) must be done upon hire & every renewal.

  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. 11 fire drills were documented in 2021. The corporation director thought that a fire drill wasn't required in the same month as the annual emergency drill.

  Corrective action. Fire drills must be practiced monthly, despite practicing an emergency drill in the same month.

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

• A licensee must (a) ensure that behavioural guidance is appropriate to the age and development of the child who is receiving the guidance.

  Observation. An employee was confirmed to have used inappropriate behavioural guidance.

  Corrective action. Corrective action required.

  14220 - CCLR s.51(1)(a)
• Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.

  Observation. There were 6 children over 36 months in a Group Child Care (under 36 months) program.

  Corrective action. Corrective action required.

  14020 - CCLR s.34(2)(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. An employee's CRC was not site specific.

  Corrective action. Corrective action required.

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

• 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. FHA reviewed 15 children's files & found that 1 lacked his immunization status.

  Corrective action. All requirements of s. 57 must be obtained by children's 1st day of care.

  19070 - CCLR s.57(2)(a)