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Vancouver “7. Central Community Health Centre Community Care Facilities Licensing CoastalHealth 132 West Esplanade, 5" Floor Promoting wens Ean ie North Vancouver, BC V7M 182 FACILITY NAME: — Happy Face Daycare ADDRESS: 1172 West 14” Street North Vancouver, BC V7P 1J8 PHONE: 604-985-8867 LICENSED CAPACITY: Group Child Care (30 Months to School Age Maximum Capacity 20) Group Child Care (Under 36 Months: Maximum Capacity 12) Group Child Care (School Age: Maximum Capacity 30), LICENCE NUMBERS: #3382445, #3382444 and #3382136 LICENSEE: North Shore Fun & Fitness Ltd This report is divided into the following sections: 1. Summary 2. Introduction 3. Mandate 4. History 5. Investigative Process 6. Facts/evidence gathering 7. Issues 8. Findings ‘9. Recommendations 10. Appendixes Community Care Facility Licences at Happy Face Daycare are currently suspended following fire and life safety concerns, Vancouver Coastal Health/North Shore Community Care Facilities Licensing (Licensing) has carried out this investigation during the suspensions as a result of long standing serious contraventions to the Community Care and Assisted Living Act and Child Care Licensing Regulation including the fire and life safety issues referenced above. The conclusion of the investigation is that Licensing recommends cancellation of the Happy Face Daycare Licences. Principle concerns leading to this conclusion are: 1) Fire and life safety issues over the past twelve years and more recent concerns since November 26, 2008, that were not adequately addressed or even brought to the attention of Licensing for consideration. 2) Despite being excluded from involvement with the daycare because of —— NN fs heen involved in the direct operations of Happy Face Daycare on an ongoing basis and has continued to be involved following suspension Promoting wellness. Ensuring care. Vancouver Coastal Health Authority ‘app Face Daycare Ivetiption Report Api 2010 '3)_ Following suspension of the Licences, Happy Face staff continued to arrange and /or care for children. A number of parents did not know where their children were being cared for or who was cating for them. 4) ee Vancouver Coastal Health’North Shore Community Care Facilities Licensing (Licensing) has concerns specific to the operation of Happy Face Daycare in regards to ongoing contraventions to the Community Care and Assisted Living Act (CCALA) and the Child Care Licensing Regulation (CLR). On March 10, 2010, Licensing received written information from the District of North Vancouver Fire and Rescue Services stating that extensive alterations and renovations had occurred in the building Presenting a significant fre and life risk to occupants. This information was clearty a contravention to Section 7 of the CCALA and CCLR, Section 13. Based upon the findings of the District of North Vancouver (DNV) Fire and Rescue Services and DNV Building and Permits Department, the licensee contravened the BC Building Code and the BC Fire Code, placing the health and safety of children in care at Happy Face Daycare at risk. Section 14 of the CCALA states: Section 14 A medical health officer may suspend a ticence, attach terms or condition to the licence, or vary the terms or conditions of that licence, without notice if the medical health officer has reasonable grounds to believe that there is an immediate risk to the health or safety of the persons in care. This information prompted summary action to suspend the facility licences on March 10, 2010. Due to the escalated health and safety risk to children in care which resulted in summary action to Suspend the facility licences and in consideration of the previous history of non-compliance, Licensing commenced an investigation on March 22, 2010 to determine the extent and severity of the Contraventions to the CCALA and the CCLR. On March 19, 2010, a previously postponed progressive enforcement meeting to discuss ongoing non- ‘compliance for the period of December 2007 until March 9, 2010 was held wi en Paul Markey, Manager, Health Protection and Glenda Burrows, Senior Child Care Licensing Officer. This was to review the contravention for the period that “am eee held the position of Manager. On March 26, 2010, __|!— requested reconsideration of the decision to suspend the licences at Happy Face Daycare and submitted “The New Happy Face Daycare Experience", Correspondence outlining proposed changes at the facility. On March 30, 2010, the Medical Health Officer, Dr. Brian O'Connor, denied the reconsideration request due to unresolved fre and life safety issues. a approval for occupancy had not been granted at 1172 W14th Street. The suspension was originally directly linked to this lack of fire ‘pproval and the risk to children. During the investigation, further concerns regarding health and safety 2 ‘apy Face Daycare ovestgnton Report Api! 2010 ‘isks have been identified and are consistent with the history of the Licensee's failure to identify and correct hazards, ‘The mandate of Licensing is to promote and protect the well being of adults and children in licensed care facilities. This is achieved by setting and monitoring the essential health, safety and care standards for licensed community care facilities ‘The purpose of this investigation is to determine whether there have been contraventions of the ‘Community Care & Assisted Living Act (CCALA) and the Child Care Licensing Regulation (CLR). Licensing provides public assurance through the mechanism of a well-defined legal framework. Medical Health Officers delegate their responsibilities prescribed in the CCALA and pursuant Regulation as an efficient and effective means of administering Community Care Facilities Licensing Programs. ‘The CCALA and its pursuant Regulation set forth a minimum standard which all licensed facities are required to meet. These standards have been developed to ensure a base level of protection for the health, safety and dignity, ofall persons in licensed care facilities throughout the Province. Section 45 (1) (b) (i) of the Community Care and Assisted Living Act states that the Medical He jealth Officer must: “Investigate every complaint that a community care facility is being operated that does not comply with this Act, the regulations or terms of conditions of its licence” An investigation under the CCALA is not a criminal investigation and therefore does not require proof beyond a reasonable doubt and is based on a balance of probabilities, This investigation report states determinations made about contraventions to the CCALA and/ or the CLR, Other Ministries such as the Ministry for Children and Family Development (MCFD) and law enforcement agencies are involved when required by Inter-ministry protocols or where potential criminal charges exist. The Licensee, operating as North Shore Fun & Fitness Ltd., was issued an Interim Permit on January 29, 1996 to operate a Community Care Facility Child Care Program then named Fun & Fitness Preschool and Child Care with a maximum capacity of 40. There have been total of 8 investigations to date during the course of the Happy Face Daycare Operation. The Licensee has operated with Conditions on the Licences since August 14, 2005 due to ‘ongoing non-compliance to the CCALA and CLR. Initially the Conditions were for a period of 12, months and requited revision on August 14, 2006, April 16, 2007 with an extension to May 31, 2007, August 13, 2007 and June 11, 2008 with conditions that remain, despite requests for reconsideration, Conditions remain in place due to the on-going contravention to the CCALA and CCLR and the licensee's repeated contravention to the conditions on the licences. This facility has been assigned a total of 14 high risk ratings and one medium risk rating forthe three licences since July 19, 2006 and the level of risk has increased since mn ™ roving from a risk rating average score of the three licences of 41 to an average Score of 58. The risk rating is for workload assessment and this facility requires frequent monitoring. Since November 2009, due to the significant incidents of non-compliance, specific to repeated infractions of the 3 ay Face DicaeIvestigntionRepr pei! 2010, ‘same sections of the legislation the Manager is required to contact Licensing on a weekly basis to review ‘outstanding issues indicated on inspection reports ‘SEE ATTACHED APPENDIX 1 FOR DETAILS ‘The Licences were suspended on March 10, 2010 due to the significant and immediate risk to health and safety of the children in care based upon the findings of the DNV Fire and Rescue Services and DNV Building and Permits Department. Licensing gathered information during the investigation through the following sources: + Interviewing of staff, parents, children and facility managers * Direct observations by Licensing ‘+ Review of facity file, inspection reports and historical investigations and Licence conditions ‘+ Communication with DNV, Building and Permits Department and DNV Fire and Rescue Services. ‘+ Alterations were made to the building at Happy Face Daycare and Licensing was not notified or were permits obtained from the District of North Vancouver. + Despite numerous inspections conducted by the District of North Vancouver Fire and Rescue Services, hazards identified were not rectified. * A total of 27 Fire inspection reports from 1998 indicating issues of concem and in violation to the BC Fire Code have been provided to the licensee requiring attention. Since July of 2008 there have been eight citations regarding fire hazards specific to tems such as local fire alarms, ‘emergency exits and adequate fire separation between the area occupied by Happy Face Daycare and the adjacent rooms where extensive renovations have occurred without the appropriate permits and approvals from the DNV. * Occupancy by the DNV Building and Permits Department and the DNV Fire and Rescue Services has not been granted, despite numerous assurances “mmm that it has been obtained. 004 the ntiative to organize child care for those families who were in ‘need of immediate care for their children by contacting two licensees of two separate fecties on the North Shore with space available, "= met with Happy Face Daycare staff at Capilano Mall and it was then that staff indicated that they would be available to care for children. Once it was decided which children would be attending the two North Shore facilities, Happy Face Daycare staff went to the facilities to care for the children who were enrolled at these facilities. Several parents were dropping their children off outside of Happy Face Daycare at 1172 West 14 Street, North Vancouver without knowledge of where their children were being taken for care. + Children were removed from care bY ae fon another licensed program without parental permission + Licensing interviewed children and confirm that | ee had 5 children in care; this is a contravention to the CCALA, Section 5 (a) (b) (c), Operating or advertising without a licence. Happy Face Daycare tnvesigmtionReprt Api 2010 * Special instruction respecting a child's diet was ignored by ———_ Candy was given to a child with food colouring and additive allergies which had previously been provided in writing by the parent when the child was initially enrolled at Happy Face Daycare * Children were transported by ——" vino did not have knowledge of emergency records, consent, and contact information. * Happy Face Daycare children’s records were used at the altemate child care program sites with Happy Face staff caring for the children placing more than the permitted number of children and allowed ages of children permitted in a Family Child Care Program * The Conditions have been breached With ___——" having direct involvement in many aspects of the delivery of services to children and families in care, as evident from the interviews with staff and parents and children. (Referenced in appendix 4) | «sme is prohibited from direct care of children following conditions placed on the Licences. * The Licensee continues fo operate this faciliy in a manner that fails to meet the required minimum standards with ongoing numerous contraventions to the CCALA and CCLR. + Licensing has made numerous concerted efforts to work with the Licensee. Despite these efforts, increased monitoring and application of conditions to the facility licences, the Licensee has continued to operate the faclty licences in contravention to the legislation. * The Licensee and management clearly disregarded the BC Building Code and the BC Fire Code, placing the health and safety of children in care at Happy Face Daycare at risk. * Although the current Manager submitted proposed changes to the administrative structure of the management team, similar restructuring initiatives have occurred on numerous occasions, and the overall impact of the restructuring has resulted in little or no improvement regarding the health and safety risks to children in care. * Despite three confirmed incidents and the follow-up of Licensing along with the creation of a transportation policy, children continue to be transported without the appropriate safety restraints since the suspension of the Licences. * The Licensee has contravened the ongoing conditions on the Licences * Despite five progressive enforcement meetings since March 19, 2008 to review contraventions to the CCALA and CCLR and ongoing discussions with the Manager regarding repeated non- compliance at the time of inspections and weekly communication with Licensing, the facility has remained with a high risk rating in the workload assessment rating tool and in actual fact the ‘score has increased since 2006. (Referenced in Appendix 3) * Continued concems regarding the demonstrated inability to provide oredible information to Licensing is evident with the contradiction to statements made regarding concems and issues. The magnitude of the investigation resulted in the need for a complete examination into the Licensee's conduct in four areas; 1) Contravention to the CALA, CCLR and non-compli the Conditions on the Licences. ‘+ On March 19, 2010 the progressive enforcement meeting originally scheduled for March 9, 2010 was held to review issues of non-compliance from the period of December 2007 until March 10, 2010, as per below. See APPENDIX 3 for details * Repeated confirmation that —_«_«<—< is involved in many aspects of the day to day operations of Happy Face Daycare, inclidind a This is in direct, ‘app Face Daycare Investigation Report Api 2010 contravention of the Conditions placed on the Licence, limiting —_—_—___ss involvement to financial matters only. 2) Events resulting in Sum ‘suspension to the F oes * March 10, 2010, Licensing received correspondence from the DNV Fire and Rescue Services stating that extensive alterations and renovations had occurred in the building presenting a significant fire and life risk to occupants. Operating a facility that presented fire and life safety hazards is clearly a contravention to CALA, Section 7, 3) Significant risk fo children during the suspension of he Licences * Children being removed from care without parental permission * Candy being given to a child with food allergies to colouring and additives demonstrates the Licensee's lack of understanding of their client base. * _Un-licensed care provided to children (more than two, not related by blood or marriage) bye . secured the placement of children registered with Happy Face Daycare in other Licensed facilities, one of which (a Family Child Care Program) was placed in contravention by having more than a maximum capacity of 7 children in care and children who do not meet the allowed ages of children in a Family Child Care Program. + Children being transported bf ES [hot knowledge of where the children’s emergency information could be located (as per their own admission). ooo ‘+ Operating the facility in contravention to the Conditions on the Licence + Failing to address fire safety issues identified by DNV ‘+ Hiring staff without the required documentation including, criminal record and health clearances + Transporting children without the required seatbelts and booster seats + Failing to identity hazards + Failing to correct hazards identified by Licensing in a timely manner, see Appendix 2 for additional details. During the investigation the licensee has failed to maintain the standards required by Section 7 of the (CCALA) Standards to be Maintained 7 (1) A licensee must do all of the following (b) operate a community care facility in a manner that will promote the health, safety and dignity of persons in care In addition the following sections of the CCLR have been identified as contravened. CCLR Requirements of a Manager - Section 18 CCLR, Section 19 A licensee must not employ a person in a community care facility unless the licensee is satisfied that; (2) (c) has the training and experience and demonstrates the skills necessary to carry out the duties assigned to the manager or employee. The Licensee/Manager contravened CLR, Section 19 (2) (c) through the following actions; ‘+ Contravening the Conditions on the Licences. Happy Face Daye investigation Report Api 2010 Operating the facility in non compliance to the legislation. Failing to identify and address fire and life safety concerns as presented by the DNV. Failing to identity hazards and correct hazards in a timely manner on an on-going basis. Hiring staff without the appropriate clearances. CLR Continuing duty to inform ~ Section 10 CCLR, Section 10 (1) Applicants for licences and licensees must notify a medical health officer immediately of any change jn the information provided under section 9 [applying for a licence}. (2) Licensees must not make any structural change to a community care facilty unless the licensee first (a) submits plans for the change fo a medical health officer, and () receives written approval from the medical health officer, The Licensee contravened CCLR, Section 10 of the legislation through the following actions; ‘+ Making changes to the facility by installing stairs to the upper portion or mezzanine without consulting Licensing | CCLR Environment - Section 13, CCLR Emergency Training and Planning - Section 22, CCLR Records ~ Section 57 and CCALA Standards to be maintained - Section 7 CLR Section 13 (1) Allicensee must ensure that a healthy and safe environment is provided at all imes while children are under the supervision of employees. CCLR Section 22 22 (1) A licensee must have all of the following: (a) emergency exits and a fire drill system approved by a local assistant within the meaning of the Fire Services Act; CCLR Section 57 57 (3) A licensee must have in wnting from @ parent, and maintain at the community care facility, consent (2) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached, and (b) to release a child to someone other than the parent. The Licensee contravened CCLR Section 13, Section 22 and Section 57 CCALA Section 7 legislation through the following actions; ‘+ Failing to respond to and address the extensive fire violations as presented by the DNV Fire and Rescue Services from multiple inspections. EE ransported children in a Happy Face Daycare van without emergency consents for children enrolled in the Group Child Care (30 Months to school age program), * Failing to respond to and address the extensive fire violations as presented by the DNV Fire and Rescue Services from multiple inspections. apy Face Daycare nvestiation Report Api 2010, transported chitéren in a Happy Face Daycare van without emergency consents for children enrolled in the Group Child Care (30 Months to school ‘age program). CCLR Hazardous objects and substances — Section 17 and CCLR Nutrition - Section 48 CCLR, Section 17 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 @ child. CCLR, Section 48 A licensee must (2) Ifa chila's record includes, or the child has a care plan that includes, instructions respecting food and drink for the child, ‘The Licensee contravened Section 17 of the CCLR, by the following actions; * Permitting to consume candy contravening the parental written instruction regarding a child's allergy to food colouring and additives. + Failing to respond to and address the extensive fire violations as presented by the DNV Fire and Rescue Services from muitiple inspections. transporting children in a Happy Face Daycare van without emergency consents for children enrolled in the Group Child Care (30 Months to school age program) CCALA Operating or advertising without a licence - Section 5 5A person who does not hold a licence must not (2) operate, or hold themselves out as operating, a community care facilty, (b) provide, or hold themselves out as providing, care in a community care facility, or (2) accommodate, or hold themselves aut as accommodating, a person who, in the opinion of @ ‘medical health officer, requires care in a community care facility The Licensee and Manager contravened Section 5 of the CCALA, by the following actions; * On the day that the Licensed Family Child Care was found in contravention with more than 7 children, ‘=== removed children from the Family Child Care program without parental permission and cared for § children at a local park. CCLR Parental access - Section 49 (1) A licensee must ensure that a parent has reasonable access to his or her child while the child is in the community care facil. (2) A licensee must not provide care to a child unless the licensee has first ensured that the child's parent or emergency contact can be readily contacted while the child is in care, The Licensee contravened CCLR Section 49 by the following actions; + meme removed children from the Family Child Care Program without consent from the parent resulting in the parent arriving and unable to have access to her child. + Parents were not notified of where their children were being taken for care. Licensee organized pick up and drop off in front of Happy Face Daycare located at 1172 West 14” Street, North Vancouver. From this location, children were taken to alternate locations, Contravention to the Conditions on the Licences Ithas been confirmed that <——_—__"_—_—=r5 contravened the conditions on the Licences by Providing direct care to children during the day to day operations at Happy Face Daycare since the Conditions were placed on the Licences, EEE has also arranged for alternate care agoy Face Dayar Investtion Report April 2010 during the Licence suspensions and has transported children during this period. (Referenced in ‘appendix 4- interviews) In the writers estimation there is litle ambiguity regarding the breaching of Conditions and the information substantiating the noted contraventions to the legislation. The Community Care and Assisted Living Act and Child Care Licensing Regulation, are minimum standards for the operation of a childcare facility, Every Licensee that is issued a Community Care Facility Licence has agreed to abide by this legislation as a measure of assurance that required standards are maintained. The legislation represents the minimum standard of which the level of care is acceptable, The extent and severity of confirmed non-compliance clearly indicates that the programs at Happy Face Daycare operated at a level below this minimum standard and is considered to put children at risk. The ‘apparent disregard of both Municipal and Provincial requirements is of significant magnitude. Despite Conditions being placed on the Licences and every attempt to allow the Licensee and Manager ‘opportunities to address issues, the level of service remains of significant concer and the facility has continued to operate in contravention to the Legislation, Contrary to the assurances to resolve issues and the Managers intent fo restructure, the lack of compliance to the legislation remains systemic. |n addition, throughout the duration of the time specific to the suspension of Licences, both the Licensee SNNMNEEE have been consistent in providing information to parents, staff, a facility operator, DNV and Licensing that has not been factual Licensing recommends that the Medical Health Officer cancel the Licences of North Shore Fun & Fitness Ltd, specific to the operation of Happy Face Daycare. ‘Should Dr. Brian O'Connor act on this recommendation, the Licensee will be entitled to provide a written response to the Medical Health Officer within 30 days, requesting Reconsideration, Akotecks Goda Lures Kitty Roberts, Glenda Burrows, Investigating Child Care Licensing Officer Senior Child Care Licensing Officer c: Dr. Brian O'Connor, Medical Health Officer, MD, MSSo Paul Markey, Manager, Health Protection This report contains confidential information which is released to the licensee for information purposes only. Use and disclosure of the content of this report is subject to the Freedom of Information and Protection and Privacy Act and other privacy legislation which protects the Personal privacy of individual apy Face Daycare lestgtion Report Apri 2010 HAPPY FACE DAYCARE INVESTIGATION April 19, 2010 The appendixes are divided into the following sections: Appendix 1- Investigation History Appendix 2~Contraventions under the Management of Appendix 3 - Progressive Enforcement Appendix 4 ~ Information collected during current investigation interviews Appendix 5 — Risk Assessments Appendix 6 ~ Letter from Manager, ——___-—~ to parents May 13, 2008, Appendix 7 Letter from Manager, ——__—_-2= to parents March 10, 2010 Appendix 8 — Photographs 10 apy Foe Daycare Investigation Report Api! 2010, ‘APPENDIX 4 Tnvestigation History Nov 18/2002 Transporting more children ‘ALL CONTRAVENTIONS; than seats available CONFIRMED * Double buckling children in vehicle ‘+ Child younger than 30 months attending facility + Qualified staff not working full ime at factlty Feb 17/2008- + Inappropriate Discipline SECTION, 17(1), 31, 32, 47 March 8/2005 | «Lack of equipment and 46 CONFIRMED + Emotional/physical abuse August Conditions on the License re 14/2005 investigation report 2005 ‘Aprii27, 2006 + Inappropriate Discipline UNSUBSTANIATED ‘+ Incomplete Children's Records CONFIRMED + Non-compliance with IT staff ratios ‘+ Non-compliance with 30+mos ratios * Breach of Conditions on Licence that ened I (71 | administration and direct care. July 23, 2007 + Lack of supervision leading to CONFIRMED inappropriate sexual play Transporting children without car seats Lack of supervision Transporting children by staff with no First Aid Certificate ‘+ Transporting children with no emergency consent forms or first aid kit + _ Breach of conditions - “in the daycare October 10, ‘+ Lack of Supervision CONFIRMED 2008 Lack of car seats UNSUBSTANITATED ‘July 27, 2008 + Breach of conditions —

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