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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CBPRQL

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
Kawaljot Bal

INSPECTION DATE
February 15, 2022
ADDITIONAL INSP. DATE (multi-day)
February 16, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.75
ARRIVAL
11:00 AM
DEPARTURE
02:30 PM
ARRIVAL
09:00 AM
DEPARTURE
10:15 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

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.


Visit the CCFL website at https://www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA and RCR).

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: 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: During inspection of common areas and hallways the following was observed:
-the baseboards, door trim and closet doors in the hallways were noted to be damaged in several areas, as evidenced by multiple dents, scuffs and missing paint.
- the rubber baseboard and air intake cover in the front living room were noted to be damaged, as evidenced by both items no longer attached to the wall.
Corrective Action(s): Ensure that all common areas are maintained in a good state of repair.
Date to be Corrected: March 16, 2022

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: During inspection a hospital bed was observed in the tub room. In discussion with the staff and manager it was determined that two of the persons in care require the bed as part of their transfer to and from the bath tub. A review of care plans for the persons in care was completed and no documentation was found for the tub room lift & transfer.
Corrective Action(s): Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: March 16, 2022.


Comments

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


Please provide a written response by March 16, 2022 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

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

(Please note: this inspection report was reviewed with the manager and then written off-site and forwarded to the Licensee. Therefore no signature was obtained.)

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
Mar 16, 2022

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