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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

JKAS-CAVUWC

FACILITY NAME Elgin House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0982079
FACILITY ADDRESS 2942 144th St			FACILITY PHONE (604) 541-0944
CITY Surrey	POSTAL CODE V4P 1P6		MANAGER Alyssa Crees

INSPECTION DATE January 21, 2022	ADDITIONAL INSP. DATE (multi-day) January 24, 2022		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 12:45 PM	DEPARTURE 02:00 PM	ARRIVAL 09:15 AM	DEPARTURE 12:00 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 4

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.

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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius. Observation (CORRECTED DURING INSPECTION): During physical walk through on day one of the inspection the hot water temperatures were taken in 3 areas. The hot water at the kitchen tap was documented at 56.1 degrees Celsius, this exceeds the required temperature. Further discussion with the manager determined the site has self identified the issue and the matter has now been resolved. Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more the 49 degrees Celsius. Date to be Corrected: Corrected during inspection.

Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report. (Please note: this inspection report was reviewed with the Licensee at the time of inspection. It was written off-site and forwarded to the Licensee. Therefore no signature was obtained.)

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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