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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-C2CTAW

FACILITY NAME
House 4
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0968012
FACILITY ADDRESS
4 - 3800 72nd St
FACILITY PHONE
(604) 946-0051
CITY
Delta
POSTAL CODE
V4K 3N2
MANAGER
George Cook

INSPECTION DATE
April 23, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:15 AM
DEPARTURE
12:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

As part of the 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 CCFL website at www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & 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: 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: There is one large shelf located in one of the PIC room that is unstable.
Corrective Action(s): Please ensure all furniture is safe.
Date to be Corrected: May 10, 2021

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: Some of the kitchen upper and lower cabinets have sections that are peeling. The staff are aware of this issue and has been brought forth.
Corrective Action(s): Please ensure the common area is in good state of repair
Date to be Corrected: May 30, 2021

STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Staff checklist was provided and evidence regarding compliance with the immunization was unavailable for all and 7 were missing their TB information
Corrective Action(s): Please ensure staff information is complete
Date to be Corrected: May 10, 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: Review of the current menu indicates that there are snack does not contain 2 food groups.
Corrective Action(s): Please ensure snack menu includes 2 food groups.
Date to be Corrected: May 10, 2021


Comments

All Policies and Procedures were recently reviewed as well as the Care plans.
Due to the COVID pandemic, the report was written offsite, but was discussed at the time of the inspection with the Manager
Please provide a written response to how the coded violations will be addressed by May 7, 2021.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
May 07, 2021

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