Braefoot Childcare Program

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

• 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. Regarding intake June 17, 2025. Through the investigation process, Licensing determined that the children were not signed out and signed back in of the facility when the children were picked up to attend an extra curricular activity outside of the facility on June 11, 2025.

  Corrective action. Ensure that a record is kept for each child in care showing daily attendance record indicating for each day whether child is absent, or if present, time of arrival and departure. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s required by Licensing: On August 22, 2025, Manager submitted a corrective action plan to Licensing. The corrective action plan included: All children would be signed out and signed back in by program staff on the attendance sheet, indicating the transfer of care when children are leaving or returning to care. The corrective action plan was reviewed and accepted by Licensing. On October 27, 2025, Licensing observed the facility had a sign in and sign out sheet for the extra curricular activity but were not signed out or back into the program to show the transfer of care.

  3070 - CCLR 57(2)(c)

• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs
  3010 - CCLR 19(1)(f)
• 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. Licensing audited 5 staff files and observed that one file had no character references.

  Corrective action. Ensure to 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 character references in respect of the person.

  3010 - CCLR 19(1)(b)
• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
  3070 - CCLR 57(2)(b)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
  3010 - CCLR 22(2)(b)

No violations recorded at this inspection.

No violations recorded at this inspection.

• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs

  Observation. Licensing audited 5 staff files and observed that 1 was missing a record of immunization.

  Corrective action. Ensure to 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: evidence that the person has complied with the Province's immunization and tuberculosis control programs.

  3010 - CCLR 19(1)(f)
• 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. Licensing audited 5 staff files and observed that one file had no character references.

  Corrective action. Ensure to 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 character references in respect of the person.

  3010 - CCLR 19(1)(b)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,

  Observation. Licensing observed that no fire drill had been recorded in Portable 2 since May 2025.

  Corrective action. Ensure that each employee practices implementing the fire drill system at least once each month.

  3010 - CCLR 22(2)(b)
• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility

  Observation. Licensing audited 9 children's files and observed that 5 were missing date of enrolment.

  Corrective action. Ensure to keep for each child, a record showing date of enrolment in the community care facility.

  3070 - CCLR 57(2)(b)

• 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. Regarding intake June 17, 2025. Through the investigation process, Licensing determined that the children were not signed out and signed back in of the facility when the children were picked up to attend an extra curricular activity outside of the facility on June 11, 2025.

  Corrective action. Ensure that a record is kept for each child in care showing daily attendance record indicating for each day whether child is absent, or if present, time of arrival and departure. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s required by Licensing: On August 22, 2025, Manager submitted a corrective action plan to Licensing. The corrective action plan included: All children would be signed out and signed back in by program staff on the attendance sheet, indicating the transfer of care when children are leaving or returning to care. The corrective action plan was reviewed and accepted by Licensing.

  3070 - CCLR 57(2)(c)

• Log kept of all inspections, maintenance & repairs
  3070 - SPS DOLSOP (Log Kept)
• The licensee must 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.
  3070 - CCLR 58(2)(b)

• A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of person in care

  Observation. Regarding intake April 8, 2025. Through the investigation process, Licensing determined that that a child who require wheel chair access was being carried up a flight of stairs.

  Corrective action. Ensure that a facility operates in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 23, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: The Licensee would ensure that barriers to accessibility are rectified by adding the gym on the main floor of the school on the licence, staff will be trained on procedures in order to prevent unsafe actions. The corrective action plan was reviewed and accepted by Licensing.

  3030 - CCALA 7(1)(b)(i)

• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
  3070 - CCLR 57(2)(b)
• A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency
  3070 - CCLR 57(2)(i)
• The licensee must 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 two care plans had not been reviewed with a parent, one since Nov 2023 and the other since Jan 2024.

  Corrective action. Ensure care plans are reviewed yearly.

  3070 - CCLR 58(2)(b)
• Log kept of all inspections, maintenance & repairs

  Observation. Licensing observed that a log of inspection for a Group Child Care (School Age) program were missing for all of January and February 2025.

  Corrective action. Ensure a record is kept of all inspections.

  3070 - SPS DOLSOP (Log Kept)
• A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.
  3080 - CCLR 11(4)
• A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid 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
  3010 - CCLR 19(4)(a)
• Despite this section, a 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: character references in respect of the person
  3010 - CCLR 19(5)(b)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
  3010 - CCLR 22(2)(b)
• A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
  3010 - CCLR 22(2)(c)
• 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]
  3010 - CCLR 56(1)(b)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.
  3070 - CCLR 57(2)(a)
• 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
  3070 - CCLR 57(2)(c)

• A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency

  Observation. Licensing audited nine children's files one was missing a photo.

  Corrective action. Ensure a photo or digital image is kept for each child.

  3070 - CCLR 57(2)(i)
• Despite this section, a 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: character references in respect of the person

  Observation. Licensing audited one volunteer file which was missing character references.

  Corrective action. Ensure character references are obatined for volunteers.

  3010 - CCLR 19(5)(b)
• A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid 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. Licensing audited four certificates for two educators and two assistant, one certificate was missing a validation for and Infant and Toddler Educator.

  Corrective action. Ensure certificates for educators or assistants are verified.

  3010 - CCLR 19(4)(a)
• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility

  Observation. Licenisng audited nine children files one was missing date of enrollment for a child in care.

  Corrective action. Ensure a record is kept showing date of enrollment.

  3070 - CCLR 57(2)(b)
• 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. Licensing audited attendace records for February 5, 6, 2025 and noted records were blank for 17 children who were in care in a Group Child Care (30 Months to School Age) program on February 6, 2025. Records for February 5, 2024 were missing sign out times for all children in care.

  Corrective action. Ensure attendance records are kept showing time of arrival and departure and if a child is present or absent.

  3070 - CCLR 57(2)(c)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.

  Observation. Licensing audited nine children's files, one was missing a medical plan number.

  Corrective action. Ensure a record is kept showing a medical plan number.

  3070 - CCLR 57(2)(a)
• 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. Licensing audited eight staff files, one was missing a character reference.

  Corrective action. Ensure character references are obatined for an employee.

  3010 - CCLR 56(1)(b)
• A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.

  Observation. Licensing observed that there was no certificate displayed for an Early Childhood Educator.

  Corrective action. Ensure a certificate for an educator or assistant is displayed in a prominent place at the community care facility.

  3080 - CCLR 11(4)
• Log kept of all inspections, maintenance & repairs

  Observation. Licensing observed that a log of inspection for a Group Child Care (School Age) program were missing for all of January and February 2025.

  Corrective action. Ensure a record is kept of all inspections.

  3070 - SPS DOLSOP (Log Kept)
• The licensee must 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 two care plans had not been reviewed with a parent, one since Nov 2023 and the other since Jan 2024.

  Corrective action. Ensure care plans are reviewed yearly.

  3070 - CCLR 58(2)(b)
• A licensee must ensure that each employee practices implementing the emergency plan at least once each year.

  Observation. Licensing observed that an emergecy drill had not been practiced for a Group Child Care (School Age) program.

  Corrective action. Ensure an emergecy drill is practiced yearly.

  3010 - CCLR 22(2)(c)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,

  Observation. Licensing observed that fire drills had not been practiced for a Group Child Care (School Age) program, Manager stated they had not been done.

  Corrective action. Ensure fire drills are practiced monthly.

  3010 - CCLR 22(2)(b)

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

• A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner (doctor's name and number does not apply to REC only) and emergency contact

  Observation. Licensing performed an audit of 10 children's files this date. One file was missing medical practitioner information.

  Corrective action. Ensure children's files contain medical practitioner information.

  3070 - CCLR 57(2)(d)
• 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. Licensing performed an audit of six staff files this date. One file did not contain character references. This item was corrected at time of inspection.

  Corrective action. Ensure staff files contain character references.

  3010 - CCLR 19(1)(b)

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

  Observation. Licensing observed that one of the three staff working in the Group Child Care (30 Months to School Age) program did not have their certificate displayed.

  Corrective action. Ensure that certificates for all educators or assistants working at the facility is displayed in a prominent place.

  3080 - CCLR 11(4)

• Height of equipment – Highest play surface as reported by Licensee or observed by LO: for toddlers (12 to 36 months) no more than .9 metres (3 feet) for preschool children (30 months to school age, no more than 1.5 metres (5 feet) for school-age children (attending school) no more than 2.3 metres (7 feet)
  3000 - SPS DOLSOP (Equipment height)
• The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.
  3070 - CCLR 58(2)(a)
• A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are safely constructed, free from hazards and in good repair.

  Observation. Licensing observed that one of the foot holds on the climbing wall in the Group Child Care (School Age) program was cracked and loose.

  Corrective action. Ensure all outdoor play material is free from hazards and in good repair.

  3000 - CCLR 16(4)(b)

• Height of equipment – Highest play surface as reported by Licensee or observed by LO: for toddlers (12 to 36 months) no more than .9 metres (3 feet) for preschool children (30 months to school age, no more than 1.5 metres (5 feet) for school-age children (attending school) no more than 2.3 metres (7 feet)

  Observation. Licensing observed that the climbing wall in the outdoor play space for the Group Child Care (School Age) program measured approximately nine feet in height. Staff stated that children climbed up and over this piece of equipment.

  Corrective action. Ensure that the highest play surface for school aged children is no more than seven feet.

  3000 - SPS DOLSOP (Equipment height)
• 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
  3010 - CCLR 19(1)(b)
• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs
  3010 - CCLR 19(1)(f)
• To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,
  3010 - CCLR 29(c)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
  3030 - CCLR 34(2)(b)
• 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 criminal record check for the person
  3010 - CCLR 19(1)(a)
• The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.

  Observation. Licensing observed there were five children with emergency medication and one child with behavioural support that did not have care plan in place.

  Corrective action. Ensure care plans for children with extra support are made in consultation with the child's parent and any person requested by the parent.

  3070 - CCLR 58(2)(a)
• A licensee must ensure that all indoor and outdoor play materials and equipment accessible to children are safely constructed, free from hazards and in good repair.

  Observation. Licensing observed that one of the foot holds on the climbing wall in the Group Child Care (School Age) program was cracked and loose.

  Corrective action. Ensure all outdoor play material is free from hazards and in good repair.

  3000 - CCLR 16(4)(b)

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

  Observation. This item was carried over from Routine Inspection dated April 4, 2023. Licensing observed an Early Childhood Educator and a Responsible Adult with 11 children in the Group Child Care (30 Months to School Age) program.

  Corrective action. Ensure ratio of employees to children is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)
• The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.

  Observation. Licensing observed there were five children with emergency medication and one child with behavioural support that did not have care plan in place.

  Corrective action. Ensure care plans for children with extra support are made in consultation with the child's parent and any person requested by the parent.

  3070 - CCLR 58(2)(a)
• Height of equipment – Highest play surface as reported by Licensee or observed by LO: for toddlers (12 to 36 months) no more than .9 metres (3 feet) for preschool children (30 months to school age, no more than 1.5 metres (5 feet) for school-age children (attending school) no more than 2.3 metres (7 feet)

  Observation. Licensing observed that the climbing wall in the outdoor play space for the Group Child Care (School Age) program measured approximately nine feet in height. Staff stated that children climbed up and over this piece of equipment.

  Corrective action. Ensure that the highest play surface for school aged children is no more than seven feet.

  3000 - SPS DOLSOP (Equipment height)
• 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 criminal record check for the person

  Observation. Licensing performed an audit of six staff files this date. One file did not contain a criminal record check (CRC).

  Corrective action. Ensure staff files contain a CRC.

  3010 - CCLR 19(1)(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: (b) character references in respect of the person

  Observation. Licensing performed an audit of three staff files. Two files were missing character references.

  Corrective action. Ensure character references have been obtained for staff.

  3010 - CCLR 19(1)(b)
• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs

  Observation. Licensing performed an audit of three staff files. One file did not contain an immunization status.

  Corrective action. Ensure an immunization status has been obtained for staff.

  3010 - CCLR 19(1)(f)
• To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,

  Observation. Licensing performed an audit of three staff files this date. One file did not show that the staff had completed a course/combination of courses of at least 20 hours duration in child development, guidance, health and safety or nutrition.

  Corrective action. Ensure a staff that is employed as a responsible adult has completed a course/combination of courses of at least 20 hours duration in child development, guidance, health and safety or nutrition.

  3010 - CCLR 29(c)
• A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.
  3070 - CCLR 57(3)(b)

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

  Observation. Licensing observed that one of the foot holds on the climbing wall in the Group Child Care (School Age) program was cracked and loose.

  Corrective action. Ensure all outdoor play material is free from hazards and in good repair.

  3000 - CCLR 16(4)(b)
• Height of equipment – Highest play surface as reported by Licensee or observed by LO: for toddlers (12 to 36 months) no more than .9 metres (3 feet) for preschool children (30 months to school age, no more than 1.5 metres (5 feet) for school-age children (attending school) no more than 2.3 metres (7 feet)

  Observation. Licensing observed that the climbing wall in the outdoor play space for the Group Child Care (School Age) program measured approximately nine feet in height. Staff stated that children climbed up and over this piece of equipment.

  Corrective action. Ensure that the highest play surface for school aged children is no more than seven feet.

  3000 - SPS DOLSOP (Equipment height)
• 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 criminal record check for the person

  Observation. Licensing performed an audit of six staff files this date. One file did not contain a criminal record check (CRC).

  Corrective action. Ensure staff files contain a CRC.

  3010 - CCLR 19(1)(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: (b) character references in respect of the person

  Observation. Licensing performed an audit of three staff files. Two files were missing character references.

  Corrective action. Ensure character references have been obtained for staff.

  3010 - CCLR 19(1)(b)
• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs

  Observation. Licensing performed an audit of three staff files. One file did not contain an immunization status.

  Corrective action. Ensure an immunization status has been obtained for staff.

  3010 - CCLR 19(1)(f)
• To qualify for employment in a community care facility as a responsible adult, a person must have completed a course, or a combination of courses, of at least 20 hours duration in child development, guidance, health and safety, or nutrition,

  Observation. Licensing performed an audit of three staff files this date. One file did not show that the staff had completed a course/combination of courses of at least 20 hours duration in child development, guidance, health and safety or nutrition.

  Corrective action. Ensure a staff that is employed as a responsible adult has completed a course/combination of courses of at least 20 hours duration in child development, guidance, health and safety or nutrition.

  3010 - CCLR 29(c)
• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
  3070 - CCLR 57(2)(b)
• A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency
  3070 - CCLR 57(2)(i)
• A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.

  Observation. Licensing performed an audit of seven children's files this date. One file did not contain consent to release to someone other than the parent.

  Corrective action. Ensure children's files contain consent to release to someone other than the parent.

  3070 - CCLR 57(3)(b)
• The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.

  Observation. Licensing observed there were five children with emergency medication and one child with behavioural support that did not have care plan in place.

  Corrective action. Ensure care plans for children with extra support are made in consultation with the child's parent and any person requested by the parent.

  3070 - CCLR 58(2)(a)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. This item was carried over from Routine Inspection dated April 4, 2023. Licensing observed an Early Childhood Educator and a Responsible Adult with 11 children in the Group Child Care (30 Months to School Age) program.

  Corrective action. Ensure ratio of employees to children is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)

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

  Observation. Licensing observed that one of the foot holds on the climbing wall in the Group Child Care (School Age) program was cracked and loose.

  Corrective action. Ensure all outdoor play material is free from hazards and in good repair.

  3000 - CCLR 16(4)(b)
• The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.

  Observation. Licensing observed there were five children with emergency medication and one child with behavioural support that did not have care plan in place.

  Corrective action. Ensure care plans for children with extra support are made in consultation with the child's parent and any person requested by the parent.

  3070 - CCLR 58(2)(a)
• A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.

  Observation. Licensing performed an audit of seven children's files this date. One file did not contain consent to release to someone other than the parent.

  Corrective action. Ensure children's files contain consent to release to someone other than the parent.

  3070 - CCLR 57(3)(b)
• A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency

  Observation. Licensing performed an audit of seven children's files. Two files were missing a photo of the child.

  Corrective action. Ensure children's files contain a photo of the child that can be used to readily identify the child in an emergency.

  3070 - CCLR 57(2)(i)
• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility

  Observation. Licensing performed an audit of seven children's files this date. One file was missing date of enrollment.

  Corrective action. Ensure children's files contain date of enrollment.

  3070 - CCLR 57(2)(b)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. This item was carried over from Routine Inspection dated April 4, 2023. Licensing observed an Early Childhood Educator and a Responsible Adult with 11 children in the Group Child Care (30 Months to School Age) program.

  Corrective action. Ensure ratio of employees to children is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)
• Height of equipment – Highest play surface as reported by Licensee or observed by LO: for toddlers (12 to 36 months) no more than .9 metres (3 feet) for preschool children (30 months to school age, no more than 1.5 metres (5 feet) for school-age children (attending school) no more than 2.3 metres (7 feet)

  Observation. Licensing observed that the climbing wall in the outdoor play space for the Group Child Care (School Age) program measured approximately nine feet in height. Staff stated that children climbed up and over this piece of equipment.

  Corrective action. Ensure that the highest play surface for school aged children is no more than seven feet.

  3000 - SPS DOLSOP (Equipment height)
• 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 criminal record check for the person

  Observation. Licensing performed an audit of six staff files this date. One file did not contain a criminal record check (CRC).

  Corrective action. Ensure staff files contain a CRC.

  3010 - CCLR 19(1)(a)

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

No violations recorded at this inspection.

• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs
  3010 - CCLR 19(1)(f)
• A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.
  3080 - CCLR 11(4)
• A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
  3080 - CCALA 7(1)(b)(i)
• Log kept of all inspections, maintenance & repairs
  3070 - SPS DOLSOP (Log Kept)
• The licensee must 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 audited two care plans of which one had not been reviewed since January 2022.

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

  3070 - CCLR 58(2)(b)
• The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.

  Observation. Licensing observed two care plans of which one did not indicate it had been developed in consultation with the parents.

  Corrective action. Ensure care plans are developed in consultation with the parent or any parent requested by the parent.

  3070 - CCLR 58(2)(a)
• A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner (doctor's name and number does not apply to REC only) and emergency contact
  3070 - CCLR 57(2)(d)
• 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
  3070 - CCLR 57(2)(c)
• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility
  3070 - CCLR 57(2)(b)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.
  3070 - CCLR 57(2)(a)
• A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
  3060 - CCLR 46(1)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing observed 16 children with one Early Childhood Educator Assistant (ECEA) and two Responsible Adults (RA) in the Group Child Care (30 Months to School Age) program. One Early Childhood Educator (ECE) and two ECEA's are required for 16 children.

  Corrective action. Ensure the ratios of employees to children is no less than that as permitted in Schedule E.

  3030 - CCLR 34(2)(b)
• 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]
  3010 - CCLR 56(1)(b)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
  3010 - CCLR 22(2)(b)
• A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid 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
  3010 - CCLR 19(4)(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: copies of any diplomas, certificates or other evidence of the person’s training and skills
  3010 - CCLR 19(1)(d)
• 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 record of the person’s work history
  3010 - CCLR 19(1)(c)
• 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
  3010 - CCLR 19(1)(b)
• 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 criminal record check for the person

  Observation. Licensing audited nine staff files of which four did not have a criminal record check.

  Corrective action. Ensure all staff have a valid criminal record check on file.

  3010 - CCLR 19(1)(a)

• A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

  Observation. Licensing observed 26 children in the Group Child Care (School Age) program in the portable. The maximum capacity licensed for the portable is 24.

  Corrective action. Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care.

  3080 - CCALA 7(1)(b)(i)
• A licensee must display in a prominent place in the community care facility the certificate of any educator or assistant employed to work in the community care facility.

  Observation. Licensing observed one educator or assistant certificate was not posted this date.

  Corrective action. Ensure certificates of all assistants and educators are displayed in a prominent place.

  3080 - CCLR 11(4)
• The licensee must 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 audited two care plans of which one had not been reviewed since January 2022.

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

  3070 - CCLR 58(2)(b)
• 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. Licensing observed one staff did not have a file.

  Corrective action. Ensure for each employee, records are kept for items required under Section 19(1).

  3010 - CCLR 56(1)(b)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing observed 16 children with one Early Childhood Educator Assistant (ECEA) and two Responsible Adults (RA) in the Group Child Care (30 Months to School Age) program. One Early Childhood Educator (ECE) and two ECEA's are required for 16 children.

  Corrective action. Ensure the ratios of employees to children is no less than that as permitted in Schedule E.

  3030 - CCLR 34(2)(b)
• A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.

  Observation. Licensing observed children in the Group Child Care (School Age) program did not wash their hands before or after eating snack. Additionally, Licensing did not observe the tables being sanitized after children ate.

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

  3060 - CCLR 46(1)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.

  Observation. Licensing audited 10 children's files of which one was missing medical insurance plan number.

  Corrective action. Ensure all children have medical insurance plan number on file.

  3070 - CCLR 57(2)(a)
• A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility

  Observation. Licensing audited 10 children's files of which eight were missing date of enrollment.

  Corrective action. Ensure all children have date of enrollment on file.

  3070 - CCLR 57(2)(b)
• 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. Licensing observed time of arrivals and departures were not documented on the attendance record in the Group Child Care (School Age) program.

  Corrective action. Ensure time of arrival and departure is documented on the attendance records.

  3070 - CCLR 57(2)(c)
• A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner (doctor's name and number does not apply to REC only) and emergency contact

  Observation. Licensing audited 10 children's files of which one was missing the name and telephone number of a medical practitioner.

  Corrective action. Ensure all children have name and telephone number of a medical practitioner on file.

  3070 - CCLR 57(2)(d)
• The licensee must develop the care plan in consultation,with a parent of the child requiring extra support and any person requested by the parent.

  Observation. Licensing observed two care plans of which one did not indicate it had been developed in consultation with the parents.

  Corrective action. Ensure care plans are developed in consultation with the parent or any parent requested by the parent.

  3070 - CCLR 58(2)(a)
• Log kept of all inspections, maintenance & repairs

  Observation. Staff stated they did not keep a log of all inspections, maintenance & repairs of the outdoor area.

  Corrective action. Ensure a log of all inspections, maintenance & repairs is kept of the outdoor area.

  3070 - SPS DOLSOP (Log Kept)
• 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 criminal record check for the person

  Observation. Licensing audited nine staff files of which four did not have a criminal record check.

  Corrective action. Ensure all staff have a valid criminal record check on file.

  3010 - CCLR 19(1)(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: (b) character references in respect of the person

  Observation. Licensing audited nine staff files of which four were missing character references.

  3010 - CCLR 19(1)(b)
• 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 record of the person’s work history

  Observation. Licensing audited nine staff files of which one was missing a resume.

  Corrective action. Ensure all staff have a record of their work history on file.

  3010 - CCLR 19(1)(c)
• 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: copies of any diplomas, certificates or other evidence of the person’s training and skills

  Observation. Licensing audited nine staff files of which three were missing copies of any diplomas, certificates or other evidence of their training.

  Corrective action. Ensure all staff have copies of any diplomas, certificates or other evidence of their training on file.

  3010 - CCLR 19(1)(d)
• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs

  Observation. Licensing audited nine staff files of which three were missing immunization status.

  Corrective action. Ensure all staff have immunization staff on file.

  3010 - CCLR 19(1)(f)
• A licensee must not employ a person in a community care facility as an educator or an assistant unless the person holds a valid 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. Licensing audited nine staff files of which one was missing validation from the ECE Registry for their certificate.

  Corrective action. Ensure all educators or assistants have their certificates validated through the ECE Registry.

  3010 - CCLR 19(4)(a)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,

  Observation. Licensing observed a fire drill had not been completed for January or March 2023.

  3010 - CCLR 22(2)(b)

No violations recorded at this inspection.

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

  Observation. Licensing observed one staff with no qualifications as a Responsible Adult (RA) working in the Group Child Care (30 Months to School Age) program covering for a break for the RA who was acting as an Early Childhood Educator Assistant (ECEA) who was absent. Licensing observed the RA come back into ratio. Additionally, Licensing observed the staff with no RA qualifications drop off two children to the facility from completing bus pick ups from school in the Group Child Care (School Age) program. A Responsible Adult is required to be in ratio at all times in the Group Child Care (School Age) program.

  Corrective action. Ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)
• 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
  3010 - CCLR 19(1)(b)
• 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: copies of any diplomas, certificates or other evidence of the person’s training and skills
  3010 - CCLR 19(1)(d)
• A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
  3060 - CCLR 46(1)

• 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: copies of any diplomas, certificates or other evidence of the person’s training and skills

  Observation. Licensing audited nine children's files and five were missing copies of any diplomas, certificates or other evidence of the person's training and skills.

  Corrective action. Ensure all staff have copies of any diplomas, certificates or other evidence of the person's training and skills on file.

  3010 - CCLR 19(1)(d)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing observed one staff with no qualifications as a Responsible Adult (RA) working in the Group Child Care (30 Months to School Age) program covering for a break for the RA who was acting as an Early Childhood Educator Assistant (ECEA) who was absent. Licensing observed the RA come back into ratio. Additionally, Licensing observed the staff with no RA qualifications drop off two children to the facility from completing bus pick ups from school in the Group Child Care (School Age) program. A Responsible Adult is required to be in ratio at all times in the Group Child Care (School Age) program.

  Corrective action. Ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)
• A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.

  Observation. Licensing observed children eating on a mat on the floor in the Group Child Care (School Age) program. Additionally, Licensing did not observed tables and mats being disinfected after children ate lunch.

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

  3060 - CCLR 46(1)
• 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. Licensing audited nine staff files and eight were missing character references.

  Corrective action. Ensure all staff have character references on file.

  3010 - CCLR 19(1)(b)

• 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: copies of any diplomas, certificates or other evidence of the person’s training and skills

  Observation. Licensing audited nine children's files and five were missing copies of any diplomas, certificates or other evidence of the person's training and skills.

  Corrective action. Ensure all staff have copies of any diplomas, certificates or other evidence of the person's training and skills on file.

  3010 - CCLR 19(1)(d)
• 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. Licensing audited nine staff files and eight were missing character references.

  Corrective action. Ensure all staff have character references on file.

  3010 - CCLR 19(1)(b)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.
  3070 - CCLR 57(2)(a)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing observed one staff with no qualifications as a Responsible Adult (RA) working in the Group Child Care (30 Months to School Age) program covering for a break for the RA who was acting as an Early Childhood Educator Assistant (ECEA) who was absent. Licensing observed the RA come back into ratio. Additionally, Licensing observed the staff with no RA qualifications drop off two children to the facility from completing bus pick ups from school in the Group Child Care (School Age) program. A Responsible Adult is required to be in ratio at all times in the Group Child Care (School Age) program.

  Corrective action. Ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)

• 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: copies of any diplomas, certificates or other evidence of the person’s training and skills

  Observation. Licensing audited nine children's files and five were missing copies of any diplomas, certificates or other evidence of the person's training and skills.

  Corrective action. Ensure all staff have copies of any diplomas, certificates or other evidence of the person's training and skills on file.

  3010 - CCLR 19(1)(d)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.

  Observation. Licensing audited 10 children's files; two of which were missing medical insurance plan numbers and one was missing immunization status.

  Corrective action. Ensure all children have medical insurance plan numbers and immunization status on file.

  3070 - CCLR 57(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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs
  3010 - CCLR 19(1)(f)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
  3030 - CCLR 34(2)(b)
• 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. Licensing audited nine staff files and eight were missing character references.

  Corrective action. Ensure all staff have character references on file.

  3010 - CCLR 19(1)(b)

• 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 record of the person’s work history
  3010 - CCLR 19(1)(c)
• 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
  3000 - CCLR 17
• Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded
  3000 - SPS DOLSOP (Inspected)
• 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 criminal record check for the person

  Observation. Licensing audited nine staff files; three had criminal record checks from a different organization and one did not have a criminal record check.

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

  3010 - CCLR 19(1)(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: (b) character references in respect of the person

  Observation. Licensing audited nine staff files and eight were missing character references.

  Corrective action. Ensure all staff have character references on file.

  3010 - CCLR 19(1)(b)
• 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: copies of any diplomas, certificates or other evidence of the person’s training and skills

  Observation. Licensing audited nine children's files and five were missing copies of any diplomas, certificates or other evidence of the person's training and skills.

  Corrective action. Ensure all staff have copies of any diplomas, certificates or other evidence of the person's training and skills on file.

  3010 - CCLR 19(1)(d)
• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs

  Observation. Licensing audited nine staff files and six were missing immunization status.

  Corrective action. Ensure all staff have immunization status on file.

  3010 - CCLR 19(1)(f)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing observed seven children in the Group Child Care (30 Months to School Age) program with a Responsible Adult (RA). An Early Childhood Educator (ECE) is required to be in ratio for this category of care.

  Corrective action. Ensure the ratio of employees to children is no less than that permitted in schedule E.

  3030 - CCLR 34(2)(b)
• A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.
  3060 - CCLR 46(1)
• A licensee must keep current records for each child showing (a) the information set out in subsection (2)
  3070 - CCLR 57(1)(a)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.

  Observation. Licensing audited 10 children's files; two of which were missing medical insurance plan numbers and one was missing immunization status.

  Corrective action. Ensure all children have medical insurance plan numbers and immunization status on file.

  3070 - CCLR 57(2)(a)
• A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency
  3070 - CCLR 57(2)(i)
• 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,
  3070 - CCLR 59(a)
• A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
  3080 - CCALA 7(1)(b)(i)
• 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.
  3080 - CCLR 11(1)

• Without limiting subsection (1) a licensee must ensure that children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E, (except FCC/IHMACC/REC; child qualified if in age range or within one month (except GCC School Age)).
  3030 - CCLR 34(2)(a)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
  3030 - CCLR 34(2)(b)

• 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: copies of any diplomas, certificates or other evidence of the person’s training and skills

  Observation. Licensing audited nine children's files and five were missing copies of any diplomas, certificates or other evidence of the person's training and skills.

  Corrective action. Ensure all staff have copies of any diplomas, certificates or other evidence of the person's training and skills on file.

  3010 - CCLR 19(1)(d)
• A licensee must keep current records for each child showing (a) the information set out in subsection (2)

  Observation. Licensing observed one child in care who did not have a registration file.

  Corrective action. Ensure records are kept for all children in care showing the information set out in subsection (2).

  3070 - CCLR 57(1)(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: (b) character references in respect of the person

  Observation. Licensing audited nine staff files and eight were missing character references.

  Corrective action. Ensure all staff have character references on file.

  3010 - CCLR 19(1)(b)
• 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 criminal record check for the person

  Observation. Licensing audited nine staff files; three had criminal record checks from a different organization and one did not have a criminal record check.

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

  3010 - CCLR 19(1)(a)
• A licensee must keep, for each child, a record showing the following information: (a)name, sex, date of birth, medical insurance plan number (MSP number does not apply to REC only) and immunization status.

  Observation. Licensing audited 10 children's files; two of which were missing medical insurance plan numbers and one was missing immunization status.

  Corrective action. Ensure all children have medical insurance plan numbers and immunization status on file.

  3070 - CCLR 57(2)(a)
• A licensee must keep, for each child, a record showing the following information:(i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency

  Observation. Licensing audited 10 children's files; one of which was missing a photo or digital image.

  Corrective action. Ensure all children have a photo or digital image on file.

  3070 - CCLR 57(2)(i)
• 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 files were not on site for Licensing to review. Manager stated over the phone they were kept offsite. Additionally, Licensing could not find the fire drill log and the outdoor play space log to review. Staff stated they did not know where they were kept.

  Corrective action. Ensure facility records referred to in Sections 56-58 are kept in a single place at the facility.

  3070 - CCLR 59(a)
• A licensee must do all of the following:(b) operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

  Observation. Licensing observed four children in care in the Group Child Care (School Age) program upon arrival at 2:00 p.m. Staff stated the children had an early dismissal and were in care at 12:00 p.m. The hours of operation on the licence for Group Child Care (School Age) indicate the program starts at 2:37 p.m. Additionally, Licensing observed attendance records for the month of September which indicated the facility was operating the Group Child Care (30 Months to School Age) program prior to September 21, 2022 when the amended licence was effective.

  Corrective action. Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care.

  3080 - CCALA 7(1)(b)(i)
• 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. Licensing did not observe the licence displayed at the facility.

  Corrective action. Ensure the licence is displayed in a prominent place at the community care facility.

  3080 - CCLR 11(1)
• Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded

  Observation. Manager stated the Group Child Care (30 Months to School Age) program did not perform or record daily inspections of the outdoor play area.

  Corrective action. Ensure thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded.

  3000 - SPS DOLSOP (Inspected)
• 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 large, heavy boxes leaning against the wall in the Group Child Care (30 Months to School Age) program.

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

  3000 - CCLR 17
• A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene.

  Observation. Licensing observed mats on the ground in the Group Child Care (30 Months to School Age) program which children sat on to eat.

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

  3060 - CCLR 46(1)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing observed seven children in the Group Child Care (30 Months to School Age) program with a Responsible Adult (RA). An Early Childhood Educator (ECE) is required to be in ratio for this category of care.

  Corrective action. Ensure the ratio of employees to children is no less than that permitted in schedule E.

  3030 - CCLR 34(2)(b)
• 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 record of the person’s work history

  Observation. Licensing audited nine staff files and two were missing a record of the person's work history.

  Corrective action. Ensure all staff have a record of their work history on file.

  3010 - CCLR 19(1)(c)
• 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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs

  Observation. Licensing audited nine staff files and six were missing immunization status.

  Corrective action. Ensure all staff have immunization status on file.

  3010 - CCLR 19(1)(f)

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

  Observation. Licensing observed 27 children in care in one group with two staff. Ratio for Group Child Care (School Age) when any preschool child or child in grade 1 is present is one Responsible Adult for every 12 children.

  Corrective action. Ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)

• A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
  3010 - CCLR 22(2)(c)
• Without limiting subsection (1) a licensee must ensure that children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E, (except FCC/IHMACC/REC; child qualified if in age range or within one month (except GCC School Age)).

  Observation. Licensing observed 27 children in care in one group. Maximum group size for Group Child Care (School Age) when any preschool child or child in grade 1 is present is 24.

  Corrective action. Ensure children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.

  3030 - CCLR 34(2)(a)
• Without limiting subsection (1), a licensee must ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  Observation. Licensing observed 27 children in care in one group with two staff. Ratio for Group Child Care (School Age) when any preschool child or child in grade 1 is present is one Responsible Adult for every 12 children.

  Corrective action. Ensure that the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.

  3030 - CCLR 34(2)(b)
• The licensee must 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.
  3070 - CCLR 58(2)(b)
• The licensee must 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.
  3070 - CCLR 58(2)(b)
• 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,
  3070 - CCLR 59(a)
• 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,
  3070 - CCLR 59(a)
• 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.
  3080 - CCLR 11(1)
• 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.
  3080 - CCLR 11(1)
• 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
  3000 - CCLR 17
• Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded
  3000 - SPS DOLSOP (Inspected)
• Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded
  3000 - SPS DOLSOP (Inspected)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
  3010 - CCLR 22(2)(b)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,
  3010 - CCLR 22(2)(b)
• A licensee must ensure that each employee practices implementing the emergency plan at least once each year.
  3010 - CCLR 22(2)(c)

• 3000 - SPS DOLSOP (Entanglement)

  Observation. Licensing used the entanglement tool to detect an entanglement on the silver slide. This represents an immediate risk to the health and safety of children in care and must be corrected immediately. Staff stated that the slide would not be used until it was corrected and approved by Licensing.

  Corrective action. Ensure equipment is free of entanglement hazards in areas of uncontrolled motion.

  3000 - SPS DOLSOP (Entanglement)
• A licensee must ensure that each employee practices implementing the fire drill system at least once each month,

  Observation. Staff stated that fire drills were not implemented each month.

  Corrective action. Ensure employees practice implementing the fire drill system at least once each month.

  3010 - CCLR 22(2)(b)
• 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. Licensing observed that children's registration forms and staff files were not on site and accessible to Licensing.

  Corrective action. Ensure records are kept in a single place at the community care facility.

  3070 - CCLR 59(a)
• A licensee must ensure that each employee practices implementing the emergency plan at least once each year.

  Observation. Staff stated that emergency drills had not been practiced at least once a year.

  Corrective action. Ensure employees practice implementing an emergency drill at least once each year.

  3010 - CCLR 22(2)(c)
• 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. Licensing observed the community care facility licence was not posted.

  Corrective action. Ensure that the facility licence is displayed in a prominent place in the community care facility.

  3080 - CCLR 11(1)
• Thorough daily, monthly and annual inspections, as well as maintenance and repairs of the outdoor play area are performed and recorded

  Observation. Licensing observed playground checks were not performed and a log was not kept.

  Corrective action. Ensure staff completes daily, weekly and monthly checks of the playground and records this information.

  3000 - SPS DOLSOP (Inspected)
• The licensee must 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 with an epi-pen did not have a care plan that was signed as reviewed by the parent within the year.

  Corrective action. Ensure the care plans are developed in consultation with parents and reviewed at least once a year.

  3070 - CCLR 58(2)(b)