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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-B8ERZU

FACILITY NAME
13330 - 20A Avenue
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982206
FACILITY ADDRESS
13330 20A Ave
FACILITY PHONE
(604) 538-1587
CITY
Surrey
POSTAL CODE
V4A 9K2
MANAGER
Gigi Rojas

INSPECTION DATE
January 14, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
09:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

An unscheduled routine inspection was conducted 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
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 sink temperature in the shower room was 51.6 degrees Celsius. The Manager contacted BC Housing who will send a Technician on January 14, 2019 to address this and install a regulator to ensure the hot water temperature is maintained at 49 degrees Celsius.
Corrective Action(s): Please ensure water accessible to a person in care from any source is not heated to more than 49 degrees Celsius.
Date to be Corrected: Please provide a written response to this item by January 14, 2019 as to when this is addressed.

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: There are black scuff marks and blue paint starting to chip and white material starting to show for example on the wall where the medication cabinet is located. The Manager stated a list has been compiled for BC Housing to paint the interior of the house; replace all the carpeting where required; wall protectors are in-place, but this has been sent to BC Housing to reassess; more cement is proposed to be added to the backyard to ensure there is more patio space and also cement to be added to the front of the house. In addition, the Manager stated that the backyard fence in some areas was patched due to the recent windstorm and eventually the entire fence will need to be replaced as it is rotting in areas. Please provide a health and safety plan to the writer for approval prior to starting any work.
Corrective Action(s): Please ensuer all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: Please keep the writer updated on the progress of addressing the items noted above.

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Fire drills are to be completed on a monthly basis. The April and June 2018 fire drills are not documented.

In random review of care plans there was a document not current for a person in care which is to be reviewed every 6 months (specifics provided to the Manager). An older version of this document is in-place. The Manager stated they will ensure this is up to date and current.
Corrective Action(s): Please ensure all the staff implement the policies and procedures.
Date to be Corrected: Please provide a written response to these items by the timeline noted in this report.


Comments

The fire extinguisher outside the tub room does not have a current service tag, however the one in the food pantry in the kitchen does. The Manager confirmed that the fire equipment was serviced and is all current. The Manager will ensure that the service tag is current. Please let the writer know when this will be addressed by.

In random review of the medication administration records there was a medication initialed by the staff on the front of the medication administration record, however the effect/result on the back of the medication administration record was a different date. The Manager stated this was an error and that the Manager will follow-up on this matter. Overall the charting in the medication administration records was thorough, therefore this item was not coded.

Regarding the uneven concrete pathway connecting 20th Avenue and 20A Avenue homes, the Manager called BC Housing and the writer spoke with the individual from BC Housing. Currently a permit has been applied for with the City of Surrey as there is a tree(s) involved that will need to be addressed which is making the concrete pathway uneven. Please keep the writer updated on this situation.

Thank you for your time to complete this routine inspection and if there are any questions, 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 LicensingFollow-up Inspection Required
Due Date
Jan 21, 2019
Approximate Follow Up Date
28 Feb, 2019

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