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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SHUN-DGEPTT

FACILITY NAME
Bright Cross Learning Center
SERVICE TYPES
301 Group Child Care (under 36 months)
302 Group Child Care (30 months to school age)
FACILITY LICENSE #
KPUL-D67TBT
FACILITY ADDRESS
13639 108th Ave
FACILITY PHONE
(778) 288-2258
CITY
Surrey
POSTAL CODE
V3T 2K4
MANAGER
Zin Mar Wintin

INSPECTION DATE
May 06, 2025
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1
ARRIVAL
09:30 AM
DEPARTURE
10:30 AM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
25

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Child Care Licensing Regulations (CCLR) and Director of Licensing Standards of Practice (DoLSoP). All care categories were inspected for compliance.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 10050 - CCLR s.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.
Observation: Licensing observed that the Manager's name wasn't posted anywhere within the facility.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 7, 2025

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11010 - CCLR s.13(1) - A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.
Observation: Licensing observed the following;
- several areas that the rubber mats are lifting in the outdoor play area. Potential tripping hazard.
- a hole between two rubber mats in the outdoor play area. Potential tripping hazard.
- two carpets curling at the corners. Potential tripping hazard
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 12, 2025

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11020 - CCLR s.13(2) - A licensee must ensure that the community care facility and the furniture, equipment and fixtures within it are clean and in good repair while children are in attendance.
Observation: Licensing observed paint chipping in several areas throughout the facility.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 12, 2025

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11200 - CCLR s.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 a child.
Observation: Licensing observed the following that are accessible to children in care;
- diaper rash ointment on a shelf in the group child care (30 months to SA) bathroom.
- blind cords in the nap room hanging low when blinds are opened. Potential strangulation hazard.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 7, 2025

STAFFING: 12090 - CCLR s.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: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Upon a random review of three staff records, Licensing observed that immunization status was not obtained for three staff.
Licensing provided further clarification on what documents were required to be obtained for staff records.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 9, 2025

POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Observation: Licensing was informed that fire drills were practiced for the months of November and December 2024 however, they were not recorded.
Corrective Action(s): Will ensure that all fire and emergency drills are recorded.
Date to be Corrected:

CARE AND/OR SUPERVISION: 14030 - CCLR s.34(2)(b) - Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E.
Observation: Upon discussion with the Manager and Director Licensing observed the following;
- There is no infant and toddler educator in the group child care (under 36 months) every morning for half an hour. An early childhood educator (ECE) is opening and present
- There is no ECE in the group child care (30 months to SA) every morning for an hour. An ECEA is opening and present.
Licensing reviewed schedule E, staff to child ratio, and ensuring that it is maintained at all times when in operation.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 7, 2025

RECORDS AND REPORTING: 19080 - CCLR s.57(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: Upon a random review of four children's records, Licensing observed that the start date was not recorded for two children's records.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 7, 2025

RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - 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: Upon a review of 8 days of the attendance records for the months of April and May 2025, Licensing observed that there were five days that children were not identified as absent.
Licensing discussed the importance of ensuring that attendance records are accurate on a daily basis.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 7, 2025

RECORDS AND REPORTING: 19100 - CCLR s.57(2)(d) - A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Observation: Upon a random review of four children's records, Licensing observed the following;
- doctor's information was not obtained for two children's records
- emergency contact information was not obtained for one child's record
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 9, 2025

RECORDS AND REPORTING: 19180 - CCLR s.57(2)(k) - A licensee must keep, for each child, a record showing the following information: (k) the date on which the child stops attending the community care facility.
Observation: Upon a review of children's records, Licensing was informed that a child no longer attends. However, the date of withdrawal was not recorded.
Corrective Action(s): A written response to be submitted to Licensing on how this contravention has been addressed.
Date to be Corrected: May 7, 2025


Comments

Summary of Inspection
At the routine inspection conducted today May 6, 2025 there were 25 children, 7 staff, and the Manager present. The Director arrived at the facility shortly after Licensing had commenced their inspection. At this inspection the above noted contraventions were identified. The Licensee is required to correct all identified non-compliances by the dates indicated above in the violations section.
A written response is to be provided to Licensing by May 12, 2025 for Licensing to review that appropriate corrective action has been taken to address all identified noncompliance. As part of this Routine Inspection a Facility Risk Assessment Tool is completed.
The following discussions were had:
- supervision
- care plans; to be reviewed at least once a year

The contents of the inspection report and risk assessment were reviewed with the Director at the time of the inspection. This report was written off site. A copy of this report and the risk assessment were emailed to the facility.
If you have any questions please do not hesitate to contact Licensing.
Visit the CCFL website at www.fraserhealth.ca/childcare for additional resources, and links to the Legislation (CCALA and CCLR).

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
May 12, 2025

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.