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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

CRAU-CLAQYP

FACILITY NAME CareLife Fleetwood		SERVICE TYPES 401 Long Term Care (Hospital Act)	FACILITY LICENSE # LBAA-962MN5
FACILITY ADDRESS 8265 159th St			FACILITY PHONE (604) 598-7200
CITY Surrey	POSTAL CODE V4N 5T5		MANAGER Inderjeet Mann / Joe Kovatch / Flora Kwong

INSPECTION DATE November 17, 2022	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 8
ARRIVAL 10:00 AM	DEPARTURE 04:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

This is a unscheduled routine inspection to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.) and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 the 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/licensed-care-facilities-and-assisted-living-providers#.YrT9QyfMI2w for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).

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 check of the hot water temperature indicated the following, for example:
* 62.2 degrees Celsius at one ensuite washroom sink.
* 63.4 degrees Celsius at one ensuite washroom sink.
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: November 18, 2022.

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: A walkthrough of the facility indicated the following, for example:
- In Cypress care neighbourhood the bottom portion of the wall material (not sure if it is a laminate) peeling off. Specifics of where this was located provided to the Manager during the inspection.
- In Willow care neighbourhood by the Nurses Station in front is a wall with a piano and the bottom left side of the wall noted with white coloured patches in various areas where paint has come off.
- In Alder care neighbourhood and throughout the facility in various areas whereby there are scuff marks, and paint chipped on door trims for bedrooms, and so on.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 31, 2023.

Comments

Policies and Procedures:
- For example the September and October 2022 fire drills were completed/conducted at the same time. Recommendation to vary the time the fire drills are conducted.
Staffing:
- The site is in process of completing performance appraisals for the staff. Please let the Licensing Officer know when responding to this routine inspection report, your plan to complete performance appraisals.
Persons in care records:
- The immunization form for a person in care on the bottom for Part B to be completed by the facility for example did not have noted who (Staff) that reviewed the document and so on. Recommendation to please ensure documents are completed in their entirety.
Due to the Covid-19 pandemic, the findings were reviewed and discussed with the Manager at the time of the inspection. This inspection report, and risk assessment was written off-site and then emailed on November 22, 2022 to the Managers for review and to finalize the report and risk assessment once they were in agreement to the wording. As a result of the pandemic, signature for the Manager is not included. If there are further questions related to this routine inspection, please contact your Licensing Officer.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	Follow-up Inspection Required
Due Date Dec 02, 2022	Approximate Follow Up Date 28 Feb, 2023

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