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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-B63RN7

FACILITY NAME
Elgin House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982079
FACILITY ADDRESS
2942 144th St
FACILITY PHONE
(604) 541-0944
CITY
Surrey
POSTAL CODE
V4P 1P6
MANAGER
Stephanie Burggraaf

INSPECTION DATE
October 31, 2018
ADDITIONAL INSP. DATE (multi-day)
October 22, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
11:30 AM
DEPARTURE
01:45 PM
ARRIVAL
10:00 AM
DEPARTURE
10:15 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
4

Introduction

An unscheduled routine inspection was initiated on October 22, 2018 and the Manager was not available. The writer completed the routine inspection on October 31, 2018 with the Interim Manager and Team Lead 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 (DLSP). 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 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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2CWtTpKipp for:

- Additional resources, and

- Links to the legislation (CCALA and RCR).

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
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Nutrition documentation under tab #19 and #20 of the person in care's chart (specific examples given to the Interim Manager and Team Lead) reviewed in April 2017.
Corrective Action(s): The nutrition documents will be reviewed to ensure they are current.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Written consent as per section 78(3)(a) of the Residential Care Regulation not noted in the person in care's chart the writer reviewed.
Corrective Action(s): Please ensure the written consent as per section 78 (3)(a) of the Residential Care Regulation is in-place for all persons in care.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.


Comments

All other areas reviewed appear to be in-compliance with the legislation.

Thank you for the time taken to complete this inspection.

If there are any questions related to this 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
Nov 20, 2018

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