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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-C2JMEV

FACILITY NAME
Crawford Manor ("A")
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
LSEO-AFXNT7
FACILITY ADDRESS
10008 128th St
FACILITY PHONE
(604) 255-0340
CITY
Surrey
POSTAL CODE
V3T 2Y9
MANAGER
Deb MacLean

INSPECTION DATE
April 28, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:30 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted 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 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. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

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

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: During inspection of the physical facility, the following was noted:
- In review of the bedroom furnishings, the dresser's and side tables in several of the rooms were extensively scratched and marked;
- The table outside the main office was noted to have laminate surfacing that was peeling off the sides and edges.
Corrective Action(s): Please ensure that furniture is maintained in a good state of repair.
Date to be Corrected: June 29, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: During inspection of the bedrooms, it was noted that persons in care do not have a safe and secure place to secure their valuables. A side table was noted in each room with a lock, however, keys were no longer available for this furniture to be used as intended.
Corrective Action(s): Please ensure each person in care has a bedroom furnishing that can be used to store valuable property.
Date to be Corrected: June 29, 2021

MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: In review of the Medication Administration Records (MAR), it was noted for a person in care that staff had handwritten all the medications on the MAR. This MAR had been in use for several weeks.
Corrective Action(s): Please ensure that the Pharmacist records all the medications on the person's medication administration record.
Date to be Corrected: May 13, 2021


Comments

This Licensing Officer would like to thank the Manager and staff for their assistance in completing this routine inspection.

Details discussed:
- A meeting with the Pharmacist is upcoming. Please ensure the following items are noted and reviewed during the Medication Safety and Advisory Committee Meeting (MSAC):
(1) Medication policies are reviewed,
(2) The orientation and training program regarding the administration of medications is reviewed,
(3) Medication errors, if applicable, are reviewed.

Please provide a written response to how the noted contraventions will be addressed by May 13, 2021.

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
May 13, 2021

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