Complaint Investigation
Inspection Information
Facility Type
Child Care - 300
Received Date
12-Dec-2023
Subject
["Staffing (Includes issues such as suitability, insufficient levels, etc.)","Health and Safety"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
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: Through the investigation process, Licensing determined there were numerous occasions between September 29, 2023 and January 4, 2024 when there was not an Early Childhood Educator working in ratio with children.
Corrective action: Ensure that the ratio of children to employees meets the requirements of Schedule E of the Child Care Licensing Regulations including during break times. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On February 8, 21, 22, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: an exemption would be applied for if there was not sufficient staff employed at the facility, Early Childhood Educators (ECEs) would not leave on a break if there was not another ECE to cover them, ratio requirements would be reviewed at the March 7, 2024, staff meeting. The corrective action plan was reviewed and accepted by Licensing. On March 7, 2024, Licensing received and email with evidence of Manager's ECE verification; on March 26, 2024, Licensing received confirmation by email of the March 14, 2024, staff meeting minutes signed by staff; on April 15, 2024, Licensing conducted a Routine Follow Up Inspection and observed the ECE certification for Manager and compliance with Schedule E.
A licensee must ensure that a child is not, while under the care or supervision of the licensee, subjected to any of the following types of abuse or neglect: emotional abuse,
Observation: Through the investigation process, Licensing determined that a staff had screamed at a child.
Corrective action: Ensure that a child was not, while under the care or supervision of the licensee, subjected to emotional abuse. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to this contravention. Action/s Required by Licensing: On February 8, 21, 22, 2024, Licensee submitted a corrective action plan. The corrective action plan included: Manager would attend the March 21, 2024, Manager Info Session with Licensing, leadership staff would attend an Incident Reporting session with Licensing by March 30, 2024, Reportable and Non Reportable Incident and Emotional Abuse Prevention Policies would be reviewed at the March 7, 2024, staff meeting. The corrective action plan was reviewed and accepted by Licensing. On March 19, 2024, leadership attended an Incident Reporting session with Licensing. On March 21, 2024, Manager attended the Manager Info Session with Licensing. On March 30, 2024, Licensing received March 14, 2024 meeting minutes showing staff had signed off on review of the Reportable and Non Reportable Incident and Emotional Abuse Prevention Policies.
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: Through the investigation process, Licensing determined that the manager did not demonstrate the skills necessary to carry out the duties assigned.
Corrective action: Ensure that the manager has the skills and abilities to carry out the duties assigned. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On February 8, 21 and 22, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the manager was registered for the March 21, 2024, Manager Info Session with Licensing, the Assistant Director would obtain regular feedback from employees regarding the manager using the Encompass Manager Evaluation Form, which would be done quarterly, a schedule had been created giving scheduled office hours for the Manager of two days per week, Assistant Director and Licensee Contact would act as mediators between the Manager and staff if conflicts arose, a chain of command and duties had been created for Licensee Contact, Assistant Director, Manager and employees, including a communication flow. The corrective action plan was reviewed and accepted by Licensing. On March 21, 2024, Manager attended the Manager Orientation with Licensing. On February 22, 2024, Licensing received evidence of the chain of command and Manager Evaluation Form.
A licensee must ensure that a child is not, while under the care or supervision of the licensee, subjected to any of the following types of abuse or neglect: emotional abuse,
Observation: Through the investigation process, Licensing determined that one staff screamed at children in care.
Corrective action: Ensure that all employees treat children with dignity. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to this contravention. Action/s Required by Licensing: On February 8, 21, 22, 2024, Licensee submitted a corrective action plan. The corrective action plan included: Manager was registered for the March 21, 2024 Manager Info Session with Licensing, leadership staff would attend an Incident Reporting session with Licensing by March 30, 2024, Reportable and Non Reportable Incident and Emotional Abuse Prevention Policies would be reviewed at the March 7, 2024 staff meeting. The corrective action plan was reviewed and accepted by Licensing. On March 19, 2024 leadership attended an incident reporting session with Licensing. On March 21, 2024 Manager attended the Manager Info Session with Licensing. On March 30, 2024 Licensing received March 14, 2024 meeting minutes showing staff had signed off on review of the Reportable and Non Reportable Incident and Emotional Abuse Prevention Policies.
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: Through the investigation process, Licensing determined that the medical health officer was not notified when a child may have been subjected to emotional abuse.
Corrective action: Ensure licensee must notify the medical health officer within 24 hours after a child is involved in or may have been involved in a reportable incident such as emotional abuse. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to this contravention. Action/s Required by Licensing: On February 8, 21, 22, 2024, Licensee submitted a corrective action plan. The corrective action plan included: leadership staff would attend an Incident Reporting session with Licensing by March 30, 2024, Reportable and Non Reportable Incident and Emotional Abuse Prevention Policies would be reviewed at the March 7, 2024 staff meeting. The corrective action plan was reviewed and accepted by Licensing. On March 19, 2024 leadership attended an incident reporting session with Licensing. On March 30, 2024 Licensing received March 14, 2024 meeting minutes showing staff had signed off on review of the Reportable and Non Reportable Incident and Emotional Abuse Prevention Policies.
A licensee must immediately notify a parent or emergency contact if, while under the care or supervision of the licensee, the child is involved in, or may have been involved in, a reportable incident described in Schedule H.
Observation: Through the investigation process, Licensing determine that a parent of a child who may have been involved in a reportable incident had not been contacted immediately regarding the incident.
Corrective action: Ensure the parent of a child who may have been involved in a reportable incident was notified immediately. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to this contravention. Action/s Required by Licensing: On February 8, 21, 22, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: leadership staff would attend an Incident Reporting session with Licensing by March 30, 2024, Reportable and Non Reportable Incident Policy would be reviewed at the March 7, 2024, staff meeting. The corrective action plan was reviewed and accepted by Licensing. On March 19, 2024, leadership attended an Incident Reporting session with Licensing. On March 30, 2024, Licensing received March 14, 2024, meeting minutes showing staff had signed off on review of the Reportable and Non Reportable Incident Policy.
A licensee must ensure that children have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,
Observation: Through the investigation process, Licensing determined between October 23, 2023 and December 13, 2023, there were several occasions when there was no staff members within immediate access to children who had a valid first aid certificate.
Corrective action: Ensure at all times children had immediate access to an employee with a valid first aid certificate. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to this contravention. Action/s Required by Licensing: On February 8, 21, 22, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a document would be created that listed certificates and expiry dates for all staff, ensure that one staff member in each room always had a valid first aid certificate. The corrective action plan was reviewed and accepted by Licensing. On February 22, 2024, Licensing received confirmation by email of staff's first aid certificates with expiration dates. On April 15, 2024, Licensing conducted a Follow Up Inspection and observed the First Aid certificates posted in each room.