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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-CQ5U8K
FACILITY NAME
CareLife Fleetwood		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962MN5
FACILITY ADDRESS
8265 159th St		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Davinda Renke / Inderjeet Mann / Flora Kwong
INSPECTION DATE
March 21, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1
ARRIVAL
11:30 AM		DEPARTURE
12:15 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

This is a follow-up inspection completed by the Licensing Officer to the routine inspection report # CRAU - CLAQYP (completed on November 17, 2022).
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: 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 review of the hot water temperature indicated the temperatures as follows:
- In Cypress House (Care Unit/Neighbourhood) the temperature at two ensuite washroom sinks measured at 63.1 and 62.9 degrees Celsius. Specifics in terms of bedroom room numbers were noted at the time of the inspection.
- Dogwood Multipurpose room sink measured at 46.1 degrees Celsius.
- Another temperature measured at 45.9 degrees Celsius.
- In the Willow House (Care Unit/Neighbourhood) the temperature at a ensuite washroom sink measured at 44.7 degrees Celsius. Specifics in terms of bedroom room number was noted at the time of the inspection.
Corrective Action(s): Please ensure that 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, 2023.
Comments

Performance Appraisals:
- There is a plan in-place to complete the performance appraisals.

Persons in care records:
- The immunization form adapted from the Community Care Facilities Licensing TB and Immunization Guideline randomly reviewed and appear to be thoroughly completed.

Physical plant/facility:
- A walk through of the facility appears to indicate the maintenance items that were needing to be addressed from the routine inspection report are now addressed. The facility has an on-going maintenance plan to address issues as they arise. For example, each house (care unit/neighbourhood) has a binder for staff to document maintenance requests and there are building committee meetings that take place as well).

Fire Drills:
- The most recent fire drill was completed in February 2023.

Thank you for all the work that was completed to address the items noted in the November 17, 2022 routine inspection report.

If there are any questions related to this follow-up inspection report, please contact your Licensing Officer.
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
Mar 22, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.