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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-CWPLJX

FACILITY NAME
Maple Ridge Treatment Centre
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
1081238
FACILITY ADDRESS
22269 Callaghan Ave
FACILITY PHONE
(604) 467-3471
CITY
Maple Ridge
POSTAL CODE
V2X 2E2
MANAGER
Melissa Thorson

INSPECTION DATE
October 17, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.15
ARRIVAL
10:15 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DOLSOP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records, and information provided by the facility staff at the time of inspection.

Care systems reviewed during inspections include:
· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records & Reporting

As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.

Visit the CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA & RCR).

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: Upon review of the staffing files, 5 out of 6 staff had not yet had their performance reviews. Management have been working on a new performance review model which is now ready to use. Performance reviews have started to take place.
Corrective Action(s): A licensee must ensure that the performance of each employee is reviewed regularly and as per the facilities own policies
Date to be Corrected: October 24 2023

POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Discussion with staff confirmed that there are insufficient supplies set aside for use in an emergency
Corrective Action(s): A licensee must have an emergency plan that sets out procedures to prepare respond and recover from an emergency.
Date to be Corrected: October 24 2023


Comments

Thanks to all staff that helps with today's inspection.

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
Oct 24, 2023

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