CEFA - Junior Kindergarten (Surrey Guildford)

• 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. Licensing observed the following; - paint chipping on the walls and doors in places throughout the facility - foam mats ripped at he corners - carpets curling and fraying

  Corrective action. A corrective action plan to be submitted to Licensing on how this contravention has been addressed.

  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. Licensing observed the following; - a blind cord hanging within children's reach. Potential strangulation hazard. The Manager fixed the cord and placed it in the hook for it. - one shelf in one of the group child care (under 36 months) program that is not secured.

  Corrective action. A corrective action plan to be submitted to Licensing on how this contravention has been addressed.

  11010 - CCLR s.13(1)
• 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 the following that are accessible to children; - a bleach and water bottle on the shelf in two group child care (30 months to SA) programs. - a child's emergency medication in their backpack.

  Corrective action. The staff and Manager moved the hazardous substances out of children's reach.

  11200 - CCLR s.17
• MEDICATION

  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's care plan identifies a prescribed emergency medication to be administered to the child in the event it is required. However, the prescribed emergency medication available at the facility does not identify who it is for or the dosage to be given.

  Corrective action. A corrective action plan to be submitted to Licensing on how this contravention has been addressed.

  16080 - CCALA s.7(1)(b)(i)
• MEDICATION

  If a licensee has agreed with a parent to give a child any medication prescribed by a medical practitioner or provided by the parent, the licensee and his or her employees must ensure that the medication is (b) readily accessible to employees.

  Observation. Licensing observed that two children's medication identified in their care plans have expired and therefore not readily accessible to employees.

  Corrective action. A corrective action plan to be submitted to Licensing on how this contravention has been addressed.

  16020 - CCLR s.53(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 (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. A corrective action plan to be submitted to Licensing on how this contravention has been addressed.

  12153 - CCLR s.19(5)(c)
• 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. A corrective action plan to be submitted to Licensing on how this contravention has been addressed.

  12152 - CCLR s.19(5)(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: (b) character references in respect of the person.

  Observation. Upon a random review of four staff records, Licensing observed that references were not obtained for one staff.

  Corrective action. A corrective action plan to be submitted to Licensing on how this contravention has been addressed.

  12050 - CCLR s.19(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. Licensing observed the following that are accessible to children in care; - bleach and water solution bottle sitting beside the diaper change mat. - tall metal ladder in one of the group child care (30 months to SA) classroom.

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

  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. Licensing observed the following; - two tall mops beside a toilet. Potential to fall on a child and hurt them. -bleach and water bottles not labelled. - fridge temperature in one of the group child care (under 36 months) classroom was measured at 8 degrees Celsius. - a tall book shelf in one of the group child care (under 36 months) classroom not secured.

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

  11010 - CCLR s.13(1)
• 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. Licensing observed the following; -one wooden panel in the playground wooden fence broken and detached. - no cover for the sandbox. The Manager said they had one but it was stolen. -a bean bag chair ripped exposing the foam underlay - a paper towel dispenser broken - a blind cord holder broken. - chipped paint throughout the facility exposing the white underlay. - a toilet seat cover broken and sitting beside the toilet.

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

  11020 - CCLR s.13(2)
• LICENSING

  A licensee must display in a prominent place in the community care facility the certificate, or a copy of the certificate, of any educator or assistant employed to work in the community care facility.

  Observation. Licensing observed that one staff's new certificate has not been posted anywhere within the facility.

  Corrective action. The Manager will post the staff's certificate in the classroom

  10070 - CCLR s.11(4)
• 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 that all the food and water in the emergency bag has expired. Licensing discussed having a system in place to ensure that the supplies are maintained.

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

  13020 - CCLR s.22(1)(b)
• 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. Licensing observed that a child's care plan was not reviewed annually with the parent or any person requested to by the parent. The care plan was last reviewed in September 2023.

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

  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: (b) character references in respect of the person.

  Observation. Upon a random review of four staff records, Licensing observed the following; - two staff's references have not been obtained - one staff only has one reference on file Licensing discussed what would meet the intent of this regulation.

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

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

  Observation. Upon a random review of four staff records, Licensing observed that immunization status was not obtained for one staff. Licensing discussed on what documents are required from staff.

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

  12090 - CCLR s.19(1)(f)
• STAFFING

  The licensee must not permit a person over the age of 12 to be ordinarily present on the premises of a community care facility while children are present, unless the person is of good character and the licensee has obtained a criminal record check for that person.

  Observation. Licensing observed that a criminal record check for an individual, over the age of 12, who is ordinarily present is not available. Licensing reviewed and explained this section of regulation with the Manager

  Corrective action. A written response to be submitted to Licensing on how this contravention has been addressed.

  12160 - CCLR s.20(1)

• 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. Wood logs throughout the temporary playground are quite slippery due to algae growth. When wet, the logs are quite slippery and may not provide alot of grip.

  Corrective action. Please provide a written response to indicate how you will address the contravention noted above on or before March 18, 2024

  11010 - CCLR s.13(1)
• 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. Multiple care plans within JK 3 classroom that require more detail in regard to course of action within the care plan. Discussion had with Manager and staff about being very detailed.

  Corrective action. Please provide a written response to indicate how you will address the contravention noted above on or before March 18, 2024

  19220 - CCLR s.58(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. The playground across the street has holes in the back fence

  Corrective action. Ensure the fence is in good repair at all times

  11020 - CCLR s.13(2)

• 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. - In the 3-5 room F, there is a green chair that is ripped and cannot be sanitized effectively; there is also one carpet that has a corner that is lifting and is a tripping hazard.

  Corrective action. Ensure all equipment and furnishings are easy to clean and free from hazards.

  11080 - CCLR s.15(1)(a)
• 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 the 3-5 room F, there was a mop and basket in the hallway that is accessible to children.

  Corrective action. Ensure any cleaning supplies are not accessible to children.

  11010 - CCLR s.13(1)
• 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 toddler room A, the washroom counter has peeled off the side. This cannot be sanitized effectively. - In the 3-5 room D, there is purple paint that has chipped off the wall

  Corrective action. Ensure the facility is in good repair at all times.

  11020 - CCLR s.13(2)
• MEDICATION

  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. There was medication on site that was expired but was needed according to a child's care plan

  Corrective action. Ensure any medication that is required due to a care plan is not expired.

  16080 - CCALA s.7(1)(b)(i)
• 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. One child's care plan was not reviewed annually with the parent or any person requested to by the parent

  Corrective action. Ensure care plans are reviewed annually and evidence of this is documented.

  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. One staff had an expired criminal record check; this staff cannot work alone with the children until a new check is obtained for them.

  Corrective action. Ensure all staff have valid, site specific, criminal record checks on file.

  12040 - CCLR s.19(1)(a)
• 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. One staff file was missing certificate validation

  Corrective action. Ensure all staff have certificate validation information on file

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

• 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. The Manager did not notify Licensing about the incident involving staff 2.

  Corrective action. Ensure to notify Licensing about any incident that would be deemed a complaint or reportable incident.

  19030 - CCLR s.55(2)(a)

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 the outdoor play space, there is a board missing from one fence panel in the 3-5 play area and there was tissue paper and other debris in the infant/toddler side.

  Corrective action. Ensure a clean and safe environment at all times while children are in care.

  11020 - CCLR s.13(2)
• 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): There was a bleach bottle in a cupboard that was not locked in room D. The staff made this bottle inaccesible.

  Corrective action. Ensure children do not have access to hazardous substances.

  11200 - CCLR s.17
• HYGIENE AND COMMUNICABLE DISEASE

  A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.

  Observation. There was no toilet paper available in the washroom in Room F.

  Corrective action. Ensure there is toilet paper available at all times and to ensure children are practising rules of proper hygiene.

  15030 - CCLR s.46(1)
• RECORDS AND REPORTING

  The licensee must (a) develop the care plan in consultation with a parent of the child requiring extra support and any person requested by the parent.

  Observation. One child who requires a care plan was missing it.

  Corrective action. Ensure to have a care plan in place for any child that requires it and that it is developed in consultation with the parent and reviewed annually.

  19250 - CCLR s.58(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. One staff file had a criminal record check that was not facility specific. There was evidence that a sharing form had been submitted for this individual. This individual cannot work alone until they recieve their new check.

  Corrective action. Ensure criminal record checks are facility specific before an individual starts to work at the facility.

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

  Observation. 3 staff files were missing immunization status

  Corrective action. Ensure staff files are complete with required information.

  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: (a) a criminal record check for the person.

  Observation. One staff was missing a criminal record check.

  Corrective action. Ensure all staff have valid criminal record checks on file that are facility specific. This staff cannot work alone with children until they obtain one.

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