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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CB8T4U
FACILITY NAME
13333 - 20th Avenue		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982205
FACILITY ADDRESS
13333 20th Ave		FACILITY PHONE
(604) 538-1635
CITY
Surrey		POSTAL CODE
V4A 1Z3		MANAGER
Kathy Gerard
INSPECTION DATE
January 31, 2022		ADDITIONAL INSP. DATE (multi-day)
February 01, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6
ARRIVAL
12:45 PM		DEPARTURE
03:00 PM		ARRIVAL
10:30 AM		DEPARTURE
12:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
4
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
·
As part of the 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 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The following observations were noted:
- The lower half of the baseboard leading to the backdoor exit and towards the main hallway had 2-3 chips measuring approximately 1/2" in depth and 1" in size.
- To the left of the baseboard leading into the main tub washroom had a chip measuring approximately 2" in length.
- The caulk near the kitchen sink is peeling off and contained areas of black residue along the sealant.
Further discussion with the manager revealed that the house will be undergoing kitchen renovations and that these observations would be corrected during the renovation. The manager is aware to submit a health and safety plan to licensing as a requirement prior to work commencing.

Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 28, 2022

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: A hospital bed was observed in the main tub room. Discussion with the manager determined that the hospital bed is required to transfer a person in care to and from the bath tub. A review of the PIC's care plan found no documentation regarding this current transfer. Further discussion with the manager confirmed that the PIC's current transfer is not current with the transfer guideline found on Share Vision.
Corrective Action(s): Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: February 28, 2022
Comments

I would like to thank the team at 13333 20th Ave for their time and assistance in the completing this inspection. If you have any questions related to this report please feel free to contact me.
Please submit a written response by February 28, 2022 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements. As per discussion with the manager, the site will be undergoing kitchen renovations and repair and no specific timeline was given at the time of the inspection. The manager is aware to submit a health and safety plan to licensing prior to work commencing.
Due to infection control practices in place related to COVID-19 prevention, this report was written off-site and is therefore unsigned. The report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Feb 28, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.