Lucky Clover Daycare Centre

• POLICIES AND PROCEDURES

  A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].

  Observation. The staff could not describe how of when they last conducted an emergency drill. The site keeps records of their monthly fire drills.

  Corrective action. Licensing discussed the difference between the annual emergency drill and the monthly fire drill.

  13050 - CCLR s.56(1)(c)
• 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. The staff described a system of drop off where all children are dropped off in one program at the beginning of the day and are sent to their respective classroom once staff arrive. However, the children are not signed in to the program where they are dropped off. At time of inspection, 5 children who were physically present in the Infant 1 were signed in to the Infant 2 program which was not operating at the time. Additionally, the facility does not have a system to track how long groups combine for and how many children in the combined groups.

  Corrective action. Licensing discussed the intent of accurate attendance.

  19090 - CCLR s.57(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. Of the five staff files inspected, two did not contain immunization records.

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

• 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 duct tape used to make some wires inaccessible to children was in disrepair causing the wires to be accessible. -An additional mattress, which did not fit snugly into the playpen was being used on top of the regular playpen mattress. Use of playpens and mattresses must be as per manufacturer's instructions and only using manufacturer's accessories.

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

  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. -The diaper change mat is cracked exposing foam. -2 small couches in the toddler program are showing beginning signs of wear and tear - some exposed foam. -Chipped paint on a windowsill which is accessible to children in the over three program.

  Corrective action. Ensure that the facility, furniture, equipment and the fixtures within it are clean and in good repair.

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

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

  Observation. The hot water in the toddler classroom was measured at 59 degrees Celsius.

  Corrective action. Ensure hot water temperature does not exceed 49 degrees Celsius.

  11230 - CCLR s.47
• 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 care plan was not dated for the purposes of annual review and one care plan was past due for annual review.

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

  19260 - CCLR s.58(2)(b)
• 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. 6 children's files were inspected and one did not contain medical insurance plan number.

  Corrective action. Ensure children's files are complete.

  19070 - CCLR s.57(2)(a)
• 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. 6 children's files were inspection and one did not contain emergency contacts and one did not contain the required medical practitioner information.

  Corrective action. Ensure children's files are complete.

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

No violations recorded at this inspection.

• 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: -Staff members' personal belongings accessible to children in care. -Blind cords accessible throughout the facility. -Licensing observed that some children's beds did not have bed sheets. A clarifying conversation with the staff indicated that some children have sheets and some do not. -Some nap mats are showing signs of wear and tear and have exposed foam. -A climbing blocks in the under three program have cracks and exposed foam. -Standing water in some equipment in the outdoor play space. -One emergency egress in the yard was locked with a padlock and the other was blocked with items stored in front of it. -Licensing observed staff using a screen during circle time in the under three program. -Licensing observed three drop down cribs in an under three nap room. Those cribs also showed signs of chipped paint. -Large amount of hand sanitizer in an unlocked cupboard in the under three nap room. -Temperature sensitive food stored on the counter top in the under three program. -Currently, the under three program which is licensed for 8 children access that room through the other under three program which is licensed for 12 children. Licensing discussed the impact of such interruption to the under three program licensed for 12 children (which is mostly infants). The door in the under three program licensed for 8 children is currently not being used. Licensing had a discussion with the Manager about making the entrance to that room useable to alleviate the stress on the other under three program.

  Corrective action. Ensure the facility is operated in a manner which is healthy and safe.

  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: -A toilet in the over three program with a cracked lid. The crack was covered with duct tape. -The wall behind a toilet in the under three program is unfinished, covered with plywood. The Licensee said that the toilet had gone through maintenance and the wall is unfinished. -There is a large amount cardboard piled up at the front of the facility. -There is debris such as insulation, piece of metal pipe, garbage bag full or used tissues in the small under three yard. -There is some overgrowth of vines with thorns in the under three yard. -There is rubber tire over a missing brick - causing a tripping hazard in one of the outdoor play spaces. -There is an unplumbed toilet by the one of the classroom entrances. The Licensee said that the toilet needs to be removed. Licensing notes that this entrance is not currently being used by the children.

  Corrective action. Ensure the community care facility and the furniture, equipment and fixtures within it are clean and in good repair.

  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. Licensing observed: -Staff member supporting children during diaper change did not change their gloves after each child and did not instruct children to wash their hands. -Several staff members were wearing gloves during the inspection. Clarifying conversation with the staff indicated that it was for when children need their noses wipes etc. Licensing discussed the importance of hand washing being the main system of communicable disease prevention. -A staff was using a bleach bottle meant for the kitchen in the bathroom causing potential for cross contamination.

  Corrective action. Ensure that a program to instruct children in, and to practice the rules of, health and hygiene is established and practiced.

  15030 - CCLR s.46(1)
• 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 (CORRECTED DURING INSPECTION): Licensing observed one staff member's certificate was not posted.

  Corrective action. Ensure all staff certificates are posted.

  10070 - CCLR s.11(4)

• If a person prepays part of the cost of services provided by a class of community care facilities designated by the Lieutenant Governor in Council, the licensee must, at the time of the prepayment, deliver to the person a written statement setting out the terms and conditions on which a refund of all or any of the prepayment will be made.

  Observation. The Licensee did not provide a written statement outlining the terms and conditions of refund to a person at the time of prepayment.

  Corrective action. Corrective action required.

  13080 - CCALA s.19

• 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. Licensee did not notify the licensing officer within 24 hours that a child was involved in or may have been involved in a reportable incident as described in Schedule H as required.

  Corrective action. Corrective action required.

  19030 - CCLR s.55(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. Criminal Record Check not obtained for two employees working in IT room.

  Corrective action. Corrective action required.

  12040 - CCLR s.19(1)(a)
• A licensee must immediately notify a parent or emergency contact if, while under the care or supervision of the licensee, the child (b) is involved in, or may have been involved in, a reportable incident described in Schedule H.

  Observation. Licensee did not notify the parent of a child who was involved in reportable incident.

  Corrective action. Corrective action required.

  19020 - CCLR s.55(1)(b)

No violations recorded at this inspection.

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.

  Observation. The following items are still outstanding at the time of the inspection from the previous routine inspection on April 6, 2022. - damaged wooden border on the school-age outdoor play area still a hazard - damaged shelf in the infant/toddler program corrected during the inspection - damaged bathroom sink counter in the Group Child Care washroom still a hazard - bushes growing through the fence on the outdoor playground a current hazard The Licensing Officer reviewed these items in depth with the manager at the time of the inspection.

  Corrective action. Ensure all indoor and outdoor play material and equipment accessible to the children in care are safely constructed, free from hazards and in good repair.

  11190 - CCLR s.16(4)(b)

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.

  Observation. The following items were observed at the time of the inspection for potential hazards to the children in care; - broken equipment on the toddler playground - lack of resilient surfacing under the school-age dome climber - damaged wooden border on the school-age outdoor play area - broken chair on the school-age outdoor play area - damaged shelf in the infant/toddler program - damaged bathroom sink counter in the Group Child Care washroom - potential of bushes on the fence line to become a hazard during the upcoming growing season The LO reviewed these items during the inspection.

  Corrective action. Ensure the indoor and outdoor play materials and equipment accessible to the children in care are safely constructed, free from hazards and in good repair.

  11190 - CCLR s.16(4)(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. On the day of the inspection the facility did not have paper towels available for hand washing. LO reviewed this item and the importance of effective hand washing and drying with the staff and management team.

  Corrective action. Ensure supplies are available to encourage, instruct and practice rules of health and hygiene.

  15030 - CCLR s.46(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. The program's attendance records were reviewed and several missing departure times were noted in the programs. LO reviewed these items with the Manager and Licensee during the inspection.

  Corrective action. Ensure accurate daily attendance is maintained including arrival and departure and absence details.

  19090 - CCLR s.57(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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.

  Observation. Five staff files were reviewed and one staff did not have a copy of any diplomas, certificates or other evidence of the person's training and skills present in the facility.

  Corrective action. Ensure all staff files are complete including certificates of the persons training and skills. Posting of ECE certificates also required.

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

  Observation. Five staff files were reviewed and three staff did not have evidence of character references being checked.

  Corrective action. Ensure staff files are complete including character references being checked.

  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. Five staff files were reviewed and two staff did not have Criminal Record Check's on file that are site specific.

  Corrective action. Ensure all staff files are complete prior to staff working with the children.

  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. Five staff files were reviewed and a record of the person's work history was not obtained for one employee.

  Corrective action. Ensure staff files are complete including a record of a person's work history.

  12060 - CCLR s.19(1)(c)
• STAFFING

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

  Observation. Two programs missed conducting fire drills for the month of March 2022.

  Corrective action. Ensure monthly fire drills are conducted and recorded.

  12190 - CCLR s.22(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. Five staff files were reviewed and one staff did not have evidence of the ECE certificate being verified by the ECE Registry.

  Corrective action. Ensure all staff files are complete including validation from the ECE Registry.

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

No violations recorded at this inspection.

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are (b) safely constructed, free from hazards and in good repair.

  Observation. The fence surrounding the outdoor play area has areas where prickle bushes are growing thru the fence posing a hazard to the children playing in the area. LO reviewed this items with the manager during the inspection.

  Corrective action. Ensure the outdoor play area is free from hazards and in good repair.

  11190 - CCLR s.16(4)(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. A fridge used to store children's perishable food items did not have a thermometer available inside the unit. LO reviewed this with the staff and manager during the inspection regarding safe storage of food items.

  Corrective action. Ensure healthy and hygienic practices are maintained in regards to the storage of food items.

  15030 - CCLR s.46(1)
• 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. The fire extinguishers in the facility have expired and require servicing. LO reviewed this with the manager during the inspection.

  Corrective action. Ensure the facility has the ability to mitigate, respond and recover from any emergency which includes yearly servicing of the fire extinguishers.

  13020 - CCLR s.22(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. Five staff files were reviewed and one staff working in the program had a CRC from a different facility in her staff file.

  Corrective action. Ensure staff files are complete including Criminal Record Checks that are facility specific.

  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. Five staff files were reviewed and one staff working in the program did not have evidence of immunization status in her file.

  Corrective action. Ensure staff files are complete including immunization status.

  12090 - CCLR s.19(1)(f)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee is satisfied, based on the information available to the licensee under subsection (1) and the licensee's or, in the case of an employee who is not the manager, the manager's own observations on meeting the person, that the person (a) is of good character.

  Observation. Five staff files were reviewed and one staff working in the program did not have evident of character references in her file.

  Corrective action. Ensure staff files are complete including references.

  12100 - CCLR s.19(2)(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 name of the facility manager is not posted in the facility. LO reviewed this item with the manager during the inspection.

  Corrective action. Ensure the name of the manager is posted in a prominent place in the facility.

  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. All the attendance records were reviewed during the inspection. One program did not have accurate records related to the departure of the children in attendance on several occasions.

  Corrective action. Ensure accurate attendance records are maintained at all times.

  19090 - CCLR s.57(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: (a) a criminal record check for the person.

  Observation. Four staff files were reviewed and two staff did not have facility specific CRC's available. LO reviewed the CRC's with the manager during the inspection.

  Corrective action. Ensure staff files are complete including CRC's that are facility specific.

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

No violations recorded at this inspection.