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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

KDHL-B2HT6H

FACILITY NAME Crestlene Lodge Ltd		SERVICE TYPES 120 Mental Health	FACILITY LICENSE # MLAO-6VQVVA
FACILITY ADDRESS 11660 86th Ave			FACILITY PHONE (604) 591-3773
CITY Delta	POSTAL CODE V4C 2X6		MANAGER Mario Tengco

INSPECTION DATE June 26, 2018	ADDITIONAL INSP. DATE (multi-day) July 09, 2018		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 5
ARRIVAL 01:30 PM	DEPARTURE 03:30 PM	ARRIVAL 01:00 PM	DEPARTURE 04:00 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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 · Polices & Procedures · Care & Supervision · Hygiene and Communicable Disease Control · Medication · Nutrition and Food Services · Program · Records and Reporting As part of the 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 CCFL website at www.fraserhealth.ca/residentialcare for: · Additional resources and · Links to the Legislation (CCALA & 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

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition. Observation (CORRECTED DURING INSPECTION): Of 5 bedrooms, 1 room closet had clothes and personal items stored on floor of closet. Corrective Action(s): Ensure all room and common areas are maintained in a safe and clean condition. Date to be Corrected: August 3, 2018 PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31820 - RCR s.36(1)(c) - A licensee must provide outside activity areas that have (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather. Observation (CORRECTED DURING INSPECTION): Review of physical facility, although a smoking gazebo was available, there lacked a reasonable amount of shelter from the sun and inclement weather for those who do not smoke. Corrective Action(s): Ensure outside areas include a reasonable amount of shelter from sun and inclement weather. Date to be Corrected: August 3, 2018

Comments

In discussion with the manager, it is recommended that the review of medication training and orientation as well as medication policies and procedures are added to the Medication Safety and Advisor Committee meetings as standing items to ensure compliance with the legislation:RCR 68(3)(a)(b)(i)(ii)

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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