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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-AETNL9
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
Jean Yngreso
INSPECTION DATE
October 17, 2016		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.75
ARRIVAL
09:15 AM		DEPARTURE
11:00 AM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
4
Introduction

This is an unscheduled routine inspection that 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 http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:

- Additional resources, and

- Links to the legislation (CCALA and RCR).
Contraventions
Previous Inspection - Contraventions observed on FIR #CRAU - A3GNMN have been corrected.
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: 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: One portion of the outdoor fence has collapsed due to the recent windstorm as noted in the report. The affected area is directly behind the dining room. The Manager stated that they have contacted BC Housing already to get this addressed. The Manager also stated the fence needs to be replaced in it's entirety as it is quite old.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: Please provide a written response by the timeline noted in this report.
Comments

Policies and Procedures:

- The writer did not review the policies and procedures as they were previously reviewed.

- The Manager advised the writer the policies and procedures are being reviewed and/or revised once a year.

- Fire drill records are in-place and drills are being completed once per month.

Care plans / Persons in care records:

- A random review of one care plan/persons in care records indicated the intent of the RCR appears to be met.

Medications:

- A review of the medication system indicated the intent of the RCR appears to be met.

Nutrition and Food Services:

- A review of the nutrition and food services systems indicated the intent of the RCR appears to be met.

Staffing:

- The Manager stated the current staffing model is sufficient to meet the care needs of the persons in care.

- A random review of one staff's documentation appeared to indicate the intent of the RCR is being met.

Physical Plant:

- Overall it appears the building is well maintained and there is an on-going maintenance plan to address any physical plant issues.

- With the recent windstorm starting on Friday, October 14, 2016 one area of the outdoor fence has collapsed. Please refer to the legislative requirement noted in this report for this item.

Thank you for your time today to complete this routine inspection. If there are any questions regarding 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
Oct 21, 2016
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.