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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

EJON-C2Y9H9

FACILITY NAME Delta House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0982514
FACILITY ADDRESS 7415 116A St			FACILITY PHONE (604) 543-0201
CITY Delta	POSTAL CODE V2X 2Z3		MANAGER Harjit Bahia

INSPECTION DATE May 11, 2021	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 10:30 AM	DEPARTURE 01:30 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted 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 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. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

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: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: In review of the physical facility, it was noted in a bedroom that a bookshelf was not secured to the wall.
Corrective Action(s): Please ensure that any furniture that is capable of falling over is appropriately secured.
Date to be Corrected: May 20, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: In the Laundry room, which is accessible to persons in care, a cleaning agent was stored on a open shelf.
Corrective Action(s): Please ensure that cleaning agents or chemical products are securely stored.
Date to be Corrected: May 13, 2021

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: In review of the menu currently being used, it was noted for the afternoon snack that only 1 food group is being offered.
Corrective Action(s): Please ensure that the menu provides 2 nutritious snacks with each snack containing at least 2 food groups.
Date to be Corrected: June 11, 2021

Comments

This Licensing Officer would like to thank the Manager and staff for their assistance in completing this routine inspection.

This report was reviewed and discussed with the Manager.

Please provide a written response to how the noted contraventions will be addressed by May 27, 2021.

Details discussed:

- In review of the Policies and procedures, specifically the Policy titled 'Incident Reporting', a list of all reportable incidents were detailed. It was noted that the reportable incident 'aggression between persons in care' was missing from the list of incidents that are reportable to Licensing.
- In review of the 'Table of Contents' for the Policy manual, it was noted that a policy is in place for 'Nutrition Care Planning'. However, it appeared that this policy was missing from the manual.
- Please ensure that the Pharmacist provides an inspection report or some form of evidence that would confirm that the medication storage area has been inspected.
- The revised 'Tuberculosis Testing and Immunization Guideline in Adult Residential Care' was forwarded to the Manager. It was explained that for new admissions under the age of 60 years a TB skin test is required. The revised guideline includes a new TB assessment form.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date May 27, 2021

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