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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KPRK-CM2S5J
FACILITY NAME
Crossroads Inlet Centre Hospice		SERVICE TYPES
110 Hospice
FACILITY LICENSE #
KSER-5RBRRL
FACILITY ADDRESS
101 Noons Creek Dr		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Sylvie Jensen
INSPECTION DATE
December 09, 2022		ADDITIONAL INSP. DATE (multi-day)
December 12, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:30 AM		DEPARTURE
11:30 AM		ARRIVAL
12:00 PM		DEPARTURE
01:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

An unscheduled follow up inspection to # CJOS-CH62UU, dated August 9, 2022 was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Annunal performance reviews for five out of ten staff were not completed.
Corrective Action(s): Ensure performance reviews are completed as required.
Date to be Corrected: January 13, 2023

STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: No evidence was provided to support training in emergency procedures such as fire drill/code red since June 2021. This is a REAT CONTRAVENTION
Corrective Action(s): Ensure each employee is trained in the implementation of emergency plans and equipment.
Date to be Corrected: January 13, 2023
Comments

Day two of the inspection was arranged based on the availability of the Clinical Manager.
Two contraventions had not been corrected from Routine Inspection # CJOS-CH62UU, dated August 9, 2022.

Please provide a response to Licensing by December 28, 2022 as to how the identified items in this report will be addressed.
This report was reviewed by the Clinical Manager and a copy was forwarded to the Facility Manager.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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
Dec 28, 2022
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