Alexandra Neighbourhood House Children's Centre At Pacific H

• 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 staff on site were unaware of whether or not there were emergency supplies on site or where they would be stored. They have not conducted an emergency evacuation drill and there was no documentation on site to confirm if one has been conducted in the past year.

  Corrective action. The Manager confirmed that the emergency plan would be reviewed with staff by the end of the week.

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

• MEDICATION

  A licensee must ensure that a child's medication is not accessible to any child, except that a child may have access to his or her own medication if (a) the child's parent has instructed the licensee to permit this.

  Observation. Medication was accessible to children in care.

  Corrective action. Ensure that medication is not accessible to children in care

  16030 - CCLR s.53(2)(a)
• OR SUPERVISION

  A licensee must ensure that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.

  Observation. Children were observed leaving the classroom and going down the hall to the bathroom with no supervision. This is a repeat contravention

  Corrective action. Ensure that children are supervised at all times.

  14060 - CCLR s.39(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. Licensing observed the emergency kit and the food provided. The food was located in cans, however, there was no equipment available to open the cans

  Corrective action. Ensure that the emergency plan has items to respond and recover from an emergency

  13020 - CCLR s.22(1)(b)
• STAFFING

  A licensee must ensure that each employee (a) is trained in the implementation of the fire drill system and emergency plan described in subsection (1), including the use of any equipment noted in the fire drill system and emergency plan.

  Observation. One employee was not aware of the implementation of the emergency plan and equipment

  Corrective action. Ensure that each employee is trained in the emergency plan

  12180 - CCLR s.22(2)(a)
• STAFFING

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

  Observation. There was no record of a fire drill being completed for Sept, October, or November.

  Corrective action. Ensure that a fire drill is practiced monthly

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

  Observation. Immunization status was not obtained for two employees.

  Corrective action. Ensure that immunization status is obtained for employees

  12090 - CCLR s.19(1)(f)
• 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. 2 employees had no record of references.

  Corrective action. Ensure that each employee has a record of reference

  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. Two employees did not have evidence of criminal record check

  Corrective action. Ensure that each employee has a record of criminal record check

  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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.

  Observation. Copies of any diplomas, certificates or other evidence of the person's training and skills were not obtained.

  Corrective action. Ensure that copies of certificates, or other evidence of the person's training and skills is obtained.

  12070 - CCLR s.19(1)(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 two person's work history was not obtained for one or more employees.

  Corrective action. Ensure each employee has a record of persons work history

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

• 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 program premise was observed to have some clutter and debris present. The program fridge/freezer was not functioning with spoiled food housed within it. The staff were not aware of this malfunction but did disposed of the spoiled food quickly once identified. Food serving practices was reviewed at the time of the inspection for suitability. The LO reviewed this with the staff at the time of the inspection.

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

  11010 - CCLR s.13(1)
• OR SUPERVISION

  A licensee must ensure that children are supervised at all times by a person who is an educator, an assistant or a responsible adult.

  Observation. Supervision of children while using the school washroom was not maintained at the time of the inspection. The LO reviewed this item in depth at the time of the inspection.

  Corrective action. Ensure children are supervised at all times.

  14060 - CCLR s.39(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. The care plan was not reviewed annually with the parent or any person requested to by the parent.

  Corrective action. Ensure all care plans are reviewed at least once a year.

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

  In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58.

  Observation. Staff records reviewed during the inspection. One staff working in the program at the time of the inspection did not have evidence of a staff file available. The LO reviewed this with the staff at the time of the inspection.

  Corrective action. Ensure staff records are available for all staff working in the program.

  19320 - CCLR s.59(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: (a) a criminal record check for the person.

  Observation. One staff working in the program did not have evidence of a criminal record check available.

  Corrective action. Ensure all staff files are complete including criminal record checks.

  12040 - CCLR s.19(1)(a)
• STAFFING

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

  Observation. Fire drill records indicated the drills have not been conducted or recorded. The LO reviewed this item with the staff at the time of the inspection.

  Corrective action. Ensure staff practice monthly fire drills and record the results.

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

• 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. A child in care had a bathroom accident and was left for 2.5 hours in soiled clothing without support or communication with the parent to pick up early. Additionally the programs cell phone shared with the parents is not effective resulting in safety concerns being present at the facility.

  Corrective action. A Licensee must ensure the health, safety and dignity of children in care is maintained at all times. This includes effective communication practices and response to bathroom accidents.

  14360 - CCALA s.7(1)(b)(i)
• If a child's record includes, or the child has a care plan that includes, instructions respecting food and drink for the child, (b) the licensee must comply with those instructions.

  Observation. A child in care was offered food items that are restricted within that child’s diet. This information was shared by the parent but not documented effectively for staff working with the child.

  Corrective action. A Licensee must ensure instructions related to food and drink are followed.

  17040 - CCLR s.48(2)(b)

• 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. Emergency Supplies are insufficient to implement the emergency plan

  Corrective action. Ensure the program has the appropriate supplies to prepare for, mitigate, respond and recover from any emergency.

  13020 - CCLR s.22(1)(b)
• 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. Three children's files were reviewed and one child did not have evidence of a Dr's name on contact details available. LO reviewed this with the manager at the time of the inspection.

  Corrective action. Ensure all children's files are complete including Dr's name and contact details.

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

No violations recorded at this inspection.