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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-CGCVQT
FACILITY NAME
Argyll Lodge		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
0982902
FACILITY ADDRESS
14590 106A Ave		FACILITY PHONE
(604) 581-4174
CITY
Surrey		POSTAL CODE
V3R 1T4		MANAGER
Baljit Kandola / Kim Keefer
INSPECTION DATE
July 15, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.25
ARRIVAL
09:30 AM		DEPARTURE
01:45 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
24
Introduction

This is a unscheduled routine inspection 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 the 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/licensed-care-facilities-and-assisted-living-providers#.YrT9QyfMI2w for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).
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: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Persons in care are involved to a certain extent with doing their own laundry. On the lower level of the facility is a clothes washing machine with a black coloured mat in front of it that moves and should be non-slip and placed on the floor in front of the machine. In addition, there is no non-slip material applied to the floor in front of the clothes drying machine either.
Corrective Action(s): Please ensure that laundry facilities if used by persons in care, have slip resistant floor surface.
Date to be Corrected: July 18, 2022.

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: There is smoking cessation documentation that staff document and initial. Some entries (specifics provided during the inspection) were not documented for. The Co-Manager will ensure this is addressed with the staff.
Corrective Action(s): Please ensure that policies and procedures are implemented by employees.
Date to be Corrected: July 18, 2022.
Comments

Medication:
* It was discussed with the Co-Manager that it is highly recommended that review of the medication policies and procedures be included as a standing agenda item to be discussed during the medication safety and advisory committee.
Nutrition Audits:
* A review of the nutrition audits indicated for example the hydration audit is dated September 2022 and this should be September 2021. Please ensure documentation is accurately documented.
Persons in care records:
* For example gender is not noted on the transfer form whereas on other documentation the gender is noted. It is best practice to ensure documentation be consistently documented on all documentation. The Co-Manager will ensure all documentation such as gender is noted on all applicable documentation.
Due to the Covid-19 pandemic, the findings were reviewed and discussed with the Co-Manager at the time of the inspection. This inspection report, and risk assessment was written off-site and then emailed on July 15, 2022 to the two Co-Managers for review and to finalize the report and risk assessment once they were in agreement to the wording. As a result of the pandemic, signature for the Co-Managers is not included. If there are further questions related to this routine inspection, please contact your Licensing Officer.
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
Jul 22, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.