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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Archway House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982510
FACILITY ADDRESS
5933 168th St
FACILITY PHONE
(604) 576-2455
CITY
Surrey
POSTAL CODE
V3S 3X5
MANAGER
Bhupinder K. (Vinder) Biln

INSPECTION DATE
April 29, 2022
ADDITIONAL INSP. DATE (multi-day)
May 03, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.75
ARRIVAL
10:00 AM
DEPARTURE
10:30 AM
ARRIVAL
10:30 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

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 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/long-term-care-licensing#.XUHwhWyos2z 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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The commode was observed the following: dark markings and chipped surfaces areas of the seat. The cloth backing color has few different markings. Leadership stated they are aware and are awaiting the approval for replacement.
Corrective Action(s): Please ensure all equipment that is used by persons in care are in a good state of repair and clean.
Date to be Corrected: June 1, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31280 - RCR s.22(1)(a) - A licensee must ensure that all rooms and common areas are (a) well ventilated.
Observation: The following was observed in the shower washroom: corner of the ceiling had water markings, the vent located on the upper wall was covered with dust. The leadership stated they were aware of this and it has been brought forth to the building maintenance company. No fixed timeline has been provided by the company.
Corrective Action(s): Please ensure the shower room is well ventilated and in good repair.
Date to be Corrected: June 6, 2022

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Monthly menu was reviewed and 2-3 days week, the breakfast menu contained two food groups from the Canada Food Guide
Corrective Action(s): Please ensure that all meals include at least 3 food groups described in the Canada Food Guide
Date to be Corrected: May 21, 2022

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: There were times that one of the snack menu only contained 1 food group from the Canada Food Guide.
Corrective Action(s): Please ensure each snack contains at least 2 food groups from the Canada Food Guide.
Date to be Corrected: May 21, 2022


Comments

The facility is utilizing the Fall/Winter menu, discussion occurred regarding menu providing seasonal variations.
Menu substitution record was reviewed and discussion regarding providing clear record of the item that was substituted along with the reason was completed.
Licensing would like to thank the staff for their assistance during this inspection.
This inspection was written off site but discussed at the time of the inspection.
Please provide a written response regarding how the contraventions will be addressed by May 16, 2022

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
May 16, 2022

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