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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SCLY-AWFVXD

FACILITY NAME
CRESST
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
0782527
FACILITY ADDRESS
33720 McDougall Ave
FACILITY PHONE
(604) 870-7583
CITY
Abbotsford
POSTAL CODE
V2S 1W4
MANAGER
Angela Donohoe

INSPECTION DATE
February 26, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
10:15 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · 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 CCFL website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: The bathtub has mold along the back wall and under the water tap.
Corrective Action(s): Ensure that the bathroom is maintained in a safe and clean condition.
Date to be Corrected: March 5, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: The bath tub does not have a slip resistant mat and the material on the bottom of the tub has the potential to be slippery when wet.
Staff stated that there use to be a mat in the tub, just as there is one in the shower, but is not sure where it is.
Corrective Action(s): Please ensure that each bathtub and shower has slip resistant material on the bottom.
Date to be Corrected: March 5, 2018

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Staff stated and showed the staff evaluations have not been completed since 2016, when they should be completed yearly.
Corrective Action(s): Please ensure that employee evaluations are conducted regularly.
Date to be Corrected: March 16, 2018

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: Discussion with staff determined that there are no audits for the menus kept on site.
This was discussed with the facility during last year's routine inspection (inspection #KDHL-AJVV95) and was made as a comment in the report to have copies of the audits on site.
Corrective Action(s): Ensure that there is evidence of the menus meeting the minimum nutrition requirements as outline in Canada's Food Guide.
Date to be Corrected: March 16, 2018


Comments

Due to technical difficulties the report was written and printed off site and delivered to the facility.

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, 2018

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