Willowbrae Academy South Surrey

• 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. A loose mat is a tripping hazard in a toddler room, and some walls in the classrooms and nap rooms have chipped paint.

  Corrective action. The manager said that they will secure the mats and the wall repair is underway.

  11010 - CCLR s.13(1)

• 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. On several dates there were not enough certified educators to meet the employee to child ratio requirement..

  Corrective action. A written response is required to be submitted to licensing by June 16, 2025, on how the licensee will ensure employee to child ratios are maintained.

  14030 - CCLR s.34(2)(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. At the time of the inspection some debris was observed stored on the outdoor play area that could pose a risk to the children. Some of the program mats showed signed of wear and tear and a blind cord was not affixed to the wall in one classroom. The LO reviewed all of these items with the manager at the time of the inspection.

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

  11010 - CCLR s.13(1)
• 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 (CORRECTED DURING INSPECTION): A minimum of two character references were not obtained for one or more employees.

  Corrective action. Ensure staff files are complete including reference checks. Corrected at the time of the inspection.

  12050 - CCLR s.19(1)(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. The behavioral guidance practices by a staff member were not consistent with the facility policies, not age appropriate and not respectful of the children in care.

  Corrective action. The Licensee has taken disciplinary actions and will be following up to ensure guidance policies are followed thoroughly by all staff at the facility.

  14220 - CCLR s.51(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. The following items were observed and identified during the inspection; - several ripped carpet/mats posing a tripping hazard - diaper change mats ripped making it difficult to effectively clean the surfaces - wall damage with exposed dry wall in several classrooms posing a risk to children - ineffective storage of nap time equipment and sheets which poses a risk to children using the equipment - garbage can in classrooms without lids that houses used food items poses a risk The Licensing officer reviewed all of these items with the manager at the time of the inspection.

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

  11010 - CCLR s.13(1)
• HYGIENE AND COMMUNICABLE DISEASE

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

  Observation. Staff are not observed to be following effective hand hygiene practices in more than one classroom at the time of the inspection.

  Corrective action. Ensure staff partake in effective hand hygiene practices.

  15030 - CCLR s.46(1)

No violations recorded at this inspection.

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. OUTDOORS - DLSOP Safe Play Space – There is insufficient shade provided to protect children from sunburn and sunstroke. Morning the 3-5 side is affected, PM the infant side is affected. INDOORS - in the majority of the classrooms, the blind cords are too loose, completely broken off the wall or the loop is broken all of these increase the risk of strangulation. - Carpets and mats are not secured to the floor and slide easily when walked on, which may cause a child to fall and injure themselves.

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

  11010 - CCLR s.13(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. A staff who works regularly, does not have a certificate posted.

  Corrective action. Ensure all certificates for IT/ECE/ECEA are posted.

  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. A site specific emergency evacuation plans is not available on site. Emergency Supplies are insufficient for the capacity of the facility. Supplies are stored in two areas and cannot be immediately accessed and transported

  Corrective action. Site specific plan must be created & implemented by all staff. Supplies must be available for all children and be able to be transported in the event that relocation is required. Licensing to email resources to support the process of creating the plan and providing the supplies.

  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. 4 children's files were reviewed, one child's file was without emergency contact information.

  Corrective action. Please ensure all children's files are current and complete prior to the child starting at the facility.

  19100 - CCLR s.57(2)(d)
• STAFFING

  A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.

  Observation. The last emergency evacuation drill was implemented on March 4th, 2022.

  Corrective action. Ensure all staff are orientated and practice implementing the emergency plan one a year. Discussions had about secondary location.

  12200 - CCLR s.22(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, Criminal Record Check not obtained for one employee. CRC was applied for on May 1, 2023

  Corrective action. Ensure all employees have a site specific CRC prior to starting employment.

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

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

  Observation. Dishes were being hand washed without the sanitization step and food was being saved, frozen and reserved after it had been in the classroom.

  Corrective action. Corrective action has been taken.

  11010 - CCLR s.13(1)
• A licensee must provide to children a comprehensive and coordinated program of indoor and outdoor activities that (c) complies with the program standards set out in Schedule G.

  Observation. Indoor and outdoor toys and activities were insufficient in quantity.

  Corrective action. Corrective action taken.

  18030 - CCLR s.44(1)(c)
• A licensee must (a) ensure that behavioural guidance is appropriate to the age and development of the child who is receiving the guidance.

  Observation. Licensing confirmed that inappropriate guidance practices were being used.

  Corrective action. Corrective action taken.

  14220 - CCLR s.51(1)(a)
• 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. Some classrooms were operating with ratios and qualifications less than permitted in Schedule E.

  Corrective action. Corrective action taken.

  14030 - CCLR s.34(2)(b)
• 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. Not all staff certificates were posted and some posted certificates were for qualified staff that no longer worked at the facility.

  Corrective action. Corrective action taken.

  10070 - CCLR s.11(4)
• 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. Some staff files were incomplete.

  Corrective action. Corrective action taken.

  12430 - CCLR s.56(1)(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. Licensing determined the health, safety, and dignity of persons in care was compromised.

  Corrective action. Corrective action required.

  14360 - CCALA s.7(1)(b)(i)
• A licensee must provide to children a comprehensive and coordinated program of indoor and outdoor activities that (b) is appropriate for the age and development of children in each group in the community care facility.

  Observation. Licensing determined that programming was not suitable to the age and development of children.

  Corrective action. Corrective action required.

  18020 - CCLR s.44(1)(b)
• 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 determined the facility did not have appropriate measures to mitigate hot weather.

  Corrective action. Corrective action required.

  11010 - CCLR s.13(1)

No violations recorded at this inspection.