Citadel Childcare Centre

• In respect of a record referred to in this Division, a licensee must (c) produce records, on demand, to the medical health officer.

  Observation. Attendance records for children prior to January 2026 were not available for Licensing to review.

  Corrective action. A licensee must be able to produce children's attendance records on demand.

  19340 - CCLR s.59(c)
• Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing determined that an Early Childhood Education Assistant worked regularly in the daycare with the Infant and Toddler Educator.

  Corrective action. Licensee must ensure that in a Group Child Care (Under 36 Months) program with 8 children, there is one Infant and Toddler Educator and the second staff is an Early Childhood Educator, as per Schedule E of the Child Care Licensing Regulation.

  14030 - CCLR s.34(2)(b)
• During an investigation or inspection, a person must not do either of the following: (b) withhold, conceal or destroy any records or information relevant to the investigation or inspection or required by the medical health officer.

  Observation. During investigation, the licensee and a staff member withheld information from Licensing regarding the staff member’s work schedule at the facility.

  Corrective action. Licensee must not withhold information from Licensing during an investigation.

  10090 - CCLR s.12(1)(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. Inside the facility, the following was observed: -Peeling paint within reach of children -Hole in drywall accessible to children -Diaper mat had rips, preventing proper cleaning -Smoke alarm sounding a high pitch consistent beep Outside the facility -Wire securing fence had sharp edged within reach of children -Peeling paint on wooden fence accessible to children

  Corrective action. The Manager stated maintenance will be addressed this week, a new diaper mat will be purchased. The smoke alarm will be serviced.

  11020 - CCLR s.13(2)
• EQUIPMENT AND FURNISHINGS

  A licensee must have first aid kits that are readily accessible to all employees, including while care is provided off the community care facility premises.

  Observation. First aid kits were not readily accessible during outdoor play.

  Corrective action. Manager stated they will bring the first aid kit during outside play moving forward

  11220 - CCLR s.23(2)

• A licensee must do all of the following

  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. The number of children in the program exceeded the facility’s maximum capacity of 8, as staff were providing care to 10 children.

  Corrective action. A licensee must not exceed the maximum capacity as per the facility licence.

  10120 - CCALA s.7(1)(b)(i)

• 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. During inspection Licensing observed: - A circular section of drywall was missing on the bathroom's top wall; the manager said it will be repaired soon. - Foam flooring in the nap room is showing signs of wear and tear; there were few sections of foam that were ripped. - Two small holes with exposed drywall were accessible to children beside the gate. - A section of one bathroom tile underneath the washroom sink was broken, exposing the floor surface underneath

  Corrective action. Manager said all these items will be fixed and photographs will be sent to Licensing within two weeks.

  11020 - CCLR s.13(2)
• HYGIENE AND COMMUNICABLE DISEASE

  A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene. Observation (CORRECTED DURING INSPECTION): During inpsection Licensing observed hand hygiene practices for children were not followed before eating routines. Licensing pointed this out to the manager, and the children's hands were washed immediately. Licensing discussed the importance of washing children's hands after each toileting/bathroom routine and before and after eating.

  Corrective action. Manager said children hands will be washed before and after eating routines.

  15030 - CCLR s.46(1)
• 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. 4 children's files were reviewed, one child was missing MSP number.During the inspection, the manager requested this information from the parent.

  Corrective action. Manager said all children files will be checked to make sure they are complete.

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

• OR SUPERVISION

  Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. During inspection Licensing observed that there was one infant toddler educator and two early childhood educator assistant staff working in the facility.

  Corrective action. Please ensure the second staff member working with an infant and toddler educator must have an ECE certificate. Licensing discussed exemption process with the manager .

  14030 - CCLR s.34(2)(b)
• 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. Licensing reviewed 4 staff files. 2 staff's certificate has not been verified through the early childhood educator registry.

  Corrective action. Please ensure ECE Certificates are verified and evidence of the verification is available before a staff starts employment.

  12140 - CCLR s.19(4)(a)

No violations recorded at this inspection.

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that any heated water accessible to children is heated to no more than 49° Celsius. Observation (CORRECTED DURING INSPECTION): Hot water in the bathroom measured at 60.5 Celsius. Manager turned off the hot water during the inspection.This is a repeat non compliance from routine inspection #SMIA-C7KSUE dated 7 October 2021.

  Corrective action. Please ensure any water accessible to children in care measures below 49 Celsius.

  11230 - CCLR s.47
• 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 (CORRECTED DURING INSPECTION): In the outdoor play area Licensing observed garden water hose was accessible to children. Licensing was concerned that it poses as a climbing,tripping and a strangulation hazard to children. Manager corrected this during inspection. This is a repeat non compliance from routine inspection #SMIA-C7KSUE dated 7 October 2021.

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

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

  A licensee must supply equipment, furniture and supplies that are (b) located so as not to block or hamper an exit in the case of fire or other emergency. Observation (CORRECTED DURING INSPECTION): During inspection Licensing observed a two-step stool, garbage can, personal use tea cup utensils, broom with dustpan stored on the staircase which is included in facility’s emergency evacuation plan. Manager removed all of these items during the inspection. This is a repeat non compliance from routine inspection #SMIA-C7KSUE dated 7 October 2021.

  Corrective action. A licensee must ensure not to block or hamper an exit in the case of fire or other emergency.

  11090 - CCLR s.15(1)(b)
• HYGIENE AND COMMUNICABLE DISEASE

  A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene. Observation (CORRECTED DURING INSPECTION): Kitchen sink is being used for washing children hands after toileting routines.Licesning is concerned of cross contamination. Education was provided to always use bathroom sink for washing hands after any toiletting routinue. Manager communicated thsi to the staff during the inspection.

  Corrective action. A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene at all times.

  15030 - CCLR s.46(1)
• NUTRITION AND FOOD SERVICES

  A licensee must (b) promote healthy eating and nutritional habits. Observation (CORRECTED DURING INSPECTION): During inspection Licensing observed a child in care walking around and drinking milk from a bottle. Licensing explained to the Manager that this was not a healthy eating habit as it was difficult to supervise the child, there may be a greater risk of choking.

  Corrective action. A Licensee must ensure to promote healthy eating habits with children.

  17020 - CCLR s.48(1)(b)

• 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 (CORRECTED DURING INSPECTION): In the outdoor play area Licensing observed water hose accessible to children. Licensing was concerned that it poses as a tripping and a strangulation hazard to children.

  Corrective action. Please ensure all equipment is stored in a way that does not pose a risk to children.

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

  A licensee must supply equipment, furniture and supplies that are (b) located so as not to block or hamper an exit in the case of fire or other emergency.

  Observation. During inspection Licensing observed a two-step stool, garbage can, Lysol spray, personal utensils, broom with dustpan and an opened ladder stored in the path used as an emergency exit. Manager removed some of these items during the inspection.

  Corrective action. Ensure not to block or hamper an exit in the case of fire or other emergency.

  11090 - CCLR s.15(1)(b)
• 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): Licensing observed spray bottle with bleach solution and Lysol spray accessible to children in the washroom.

  Corrective action. Ensure that children do not have access to any object or substance that may be hazardous to the health or safety of a child.

  11200 - CCLR s.17
• EQUIPMENT AND FURNISHINGS

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

  Observation. Hot water in the kitchen measured at 56.7 Celsius. Licensee stated that children sometimes wash their hands in the kitchen and are supervised while washing hands.

  Corrective action. Please ensure any water accessible to children in care measures below 49 Celsius.

  11230 - CCLR s.47

• 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. Hazadrous products(diaper creams) were accessible to the children.

  Corrective action. Please ensure that all hazadrous substances are not accessible to children.

  11200 - CCLR s.17
• POLICIES AND PROCEDURES

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

  Observation. Fire extinguisher has not been serviced since june 2020.

  Corrective action. Please ensure that there is an emergency plan in place to respond and recover from any emergency.

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

  Despite subsection (2)(a) and (d), a licensee who provides a care program described as Child-minding must do all of the following: (b) if a child's immunization status is not reasonably known or available to the child's parent, keep a record detailing as much information as is known respecting the child's immunization status.

  Observation. 8 children's files were reviewed and they were incomplete for immunization status.

  Corrective action. Please ensure all files are complete with immunization records.

  19182 - CCLR s.57(2.1)(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. Three staff files were reviewed and the following was noted: - The Licensee's CRC had expired on 14 July 2020 - One staff did not have a CRC completed through the Criminal Record Review Program - One staff CRC is from another organization

  Corrective action. Please ensure CRC's are valid, specific to the facility and obtained through Criminal Record Review Program

  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. Two out of three staff files were missing evidence of immunization status.

  Corrective action. Please ensure that staff files are complete as per the requirements of the legislation.

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

  Observation. Three staff files were reviewed and three were missing validation from the ECE registry

  Corrective action. Please ensure ECE certificates are validated through the ECE registry and evidence of which is kept in their files.

  12140 - CCLR s.19(4)(a)