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

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
March 08, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
10:30 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
9

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 & 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
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Review of 3 employee files, all 3 files do not have evidence of completed criminal record checks. This is a repeat contravention.
Corrective Action(s): Ensure that criminal record checks are obtained for all employees.
Date to be Corrected: April 5, 2022.

STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: Review of 3 employee files, 1 had evidence of 1 reference check and 1 had no evidence of reference checks on file.
Corrective Action(s): Ensure that reference checks are obtained for employees.
Date to be Corrected: April 5, 2022

STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Review of 3 staff files, 3 of 3 have expired registration with the BC College of Nurses and Midwives on file, expired in February of 2021.
Corrective Action(s): Ensure that copies of diplomas, certificates or other evidence of a person's training and skills are obtained.
Date to be Corrected: April 5, 2022.

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: Review of 3 employee files, 2 of 3 files did not have evidence of compliance with the Province's immunization and tuberculosis control programs. This is a repeat contravention.
Corrective Action(s): Ensure that evidence of compliance with the Provincial immunization and tuberculosis control programs is obtained for employees.
Date to be Corrected: April 5, 2022

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 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Review of 3 employee files, 3 of 3 did not have evidence of a current performance review on file. This is a repeat contravention.
Corrective Action(s): Ensure that performance of employees is reviewed both regularly and as directed by the medical health officer.
Date to be Corrected: April 5, 2022.

STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: Review of 3 employee files, 3 of 3 files did not have evidence of a current first aid and CPR certificate, 1 expired in 2019 and 2 expired in 2021. This is a repeat contravention.
Corrective Action(s): Ensure that all employees who require first aid and CPR certification have a current/valid certificate.
Date to be Corrected: April 5, 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 April 5, 2022 indicating the corrective actions taken and/or time line 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: due to infection control practices related to COVID-19 prevention, this inspection report was reviewed on-site, 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
Apr 05, 2022

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