LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation (CORRECTED DURING INSPECTION): A review of the menu checklist dated February 19, 2022, Part B was not completed. The staff completed this on-site. Please ensure the documentation is completed as required based on the program at CRESST - South Fraser (Part B refers to the length of the menu, however the program is a "short term" program).
There is one satisfaction survey with no date on it. In discussion with the staff, the survey was completed close to the other surveys being completed and a summary of the survey includes this survey with no date. Please ensure all documentation is thoroughly completed including dates, and so on.
Corrective Action(s): Please ensure the care and services provided by the facility are monitored regularly to ensure that the requirements of the Community Care & Assisted Living Act and Residential Care Regulation are being met.
Date to be Corrected: March 22, 2022.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: A random check of the hot water temperatures at the sources accessible to persons in care indicated the following:
- The person in care washroom adjacent to the dining room/back offices the sink hot water temperature measured at 58.7 degrees Celsius (slowly rose to this temperature and likely would have risen higher).
Corrective Action(s): Please ensure that the water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: March 22, 2022.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The Manager advised the writer that new furnishings are now in-place such as dressers, and sofa. The Manager stated working with BC Housing to address the outstanding maintenance items (e.g., patched the walls where required and painting needs to be completed). The Manager provided the Licensing Officer a list of maintenance items needing to be addressed (dated August 12, 2021) that BC Housing has been made aware of.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 30, 2022.
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