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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

CRAU-APNU5L

FACILITY NAME Peace Portal Seniors Village		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # LSEO-AG9SW5
FACILITY ADDRESS 15441 16th Ave			FACILITY PHONE (604) 535-2273
CITY Surrey	POSTAL CODE V4A 8T8		MANAGER Glenn Hocking

INSPECTION DATE July 27, 2017	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 7
ARRIVAL 09:45 AM	DEPARTURE 04:45 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED 74

Introduction

This is an unscheduled routine inspection conducted with the General Manager and Director of Care to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.) and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 the inspection.

The following areas were reviewed:

- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this 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 Community Care Facilities Licensing website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).

Contraventions

Previous Inspection - Not Applicable

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

Observed Violations

STAFFING: 32040 - RCR s.37(1)(d) - 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 obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: For 1 of the 4 staff files reviewed, one staff's copy of their diploma/evidence of the program they took will be needing to be placed on their personnel file.
Corrective Action(s): Please ensure all staff have documentation on their personnel files relating to copies of any diplomas, certificates or other evidence of the person's training and skills.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.

STAFFING: 32260 - RCR s.44(1)(b) - A licensee must ensure that employees responsible for the preparation and delivery of food (b) receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques.
Observation: The writer was not able to review the on-going nutrition education as the information was not available. The writer requested documentation for all of the year 2016 and year 2017 currently.
Corrective Action(s): Please forward the education schedule for year 2016 and the attendance records for staff for each in-service. Please ensure that on-going education for nutrition is completed on a regular basis.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.

Comments

Policies and Procedures:

- The policies and procedures are being reviewed and/or revised once a year.

Community Care Facilities Licensing:

- The licence is posted.

- The resident bill of rights is accessible.

- The patient care quality office poster(s) are accessible.

- The last routine inspection report is posted.

- Liability insurance is in-place.

Staffing:

- In discussion with the General Manager, the writer was advised that the current staffing model is sufficient to meet the care needs of the persons in care.

- A random review of four staff files was conducted. The item noted with the applicable legislative requirement in this report needs to be addressed.

Care plans/Persons in care records:

- A review of the care planning system and a random review of five care plans overall indicated that the intent of the Residential Care Regulation is being met. The writer will e-mail to the Director of Care the updated Community Care Facilities Licensing guideline for persons in care on tuberculosis and immunizations as there are standardized forms that can be utilized for tuberculosis and immunizations.

Medications:

- A review of the medication system and a random review of the medication room/cart on the 2nd floor appeared to indicate that the intent of the Residential Care Regulation is being met.

Physical Plant:

- The building on the interior has gone extensive upgrades which appears to have brightened up the facility with new pictures, paint on the walls, etc. Exterior work is starting which the writer was made aware of and the work will not affect the health and safety of the persons in care. Thank you for keeping the writer updated on the plans to upgrade the facility.

- The first aid kit in the 2nd floor medication room has a checklist to be completed as part of an audit. The kit was last documented as being audited in September 2016. The Manager stated they will follow-up on this as it should be checked on a monthly basis. Recommendation to check the first aid kits on a regular basis. Please let the writer know how this will be addressed.

Nutrition and Food Services:

- The writer met with the Food Services Manager and it appears overall the systems in-place meet the intent of the Residential Care Regulation. The one item around on-going nutrition education referenced with the applicable Residential Care Regulation section as noted in this report needs to be addressed.

Summary:

- After completing this inspection it appears there are thorough systems in-place and overall the building is well maintained. If you have any questions regarding this report, please contact your Licensing Officer.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Aug 18, 2017

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