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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CHJM6P
FACILITY NAME
Crawford Manor ("A")		SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
LSEO-AFXNT7
FACILITY ADDRESS
10008 128th St		FACILITY PHONE
(604) 255-0340
CITY
Surrey		POSTAL CODE
V3T 2Y9		MANAGER
Deb MacLean
INSPECTION DATE
August 18, 2022		ADDITIONAL INSP. DATE (multi-day)
August 23, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
10:00 AM		DEPARTURE
12:00 PM		ARRIVAL
10:00 AM		DEPARTURE
12:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
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: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: It was observed that persons in care do not have bedroom furnishings that provide a safe, secure place to store valuables. Locked were noted on some bedside tables on some bedrooms, however, keys were not available for use. It was mentioned that when this facility was originally licensed all bedrooms were furnished with a bedside table that was able to be locked.
Corrective Action(s): Please ensure that each person in care is provided with bedroom furnishings that inlcudes a safe, secure place to store valuables.
Date to be Corrected: October 21, 2022

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 downstairs shower stall did not have a slip resistant material on the bottom.
Corrective Action(s): Please ensure all bathrooms have slip resistant material on the bottom of each shower and bathtub.
Date to be Corrected: September 9, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Containers of bleach and various cleaning agents were noted to be unsecured in the vanity of the lower level washroom.
Corrective Action(s): Please ensure safe and secure storage of cleaning agents.
Date to be Corrected: September 2, 2022

POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: During this inspection, an emergency supply of 'food and water' could not be located.
Corrective Action(s): Please ensure that an adequate amount of food and water is available to ensure persons in care can be cared for in the event of an emergency.
Date to be Corrected: September 2, 2022
Comments

This Licensing Officer would like to thank the Manager and staff for their assistance in completing this routine inspection.

Details discussed:
- A meeting with the Pharmacist is upcoming. Please ensure the following items are noted and reviewed during the Medication Safety and Advisory Committee Meeting (MSAC):
(1) Medication policies are reviewed,
(2) The orientation and training program regarding the administration of medications is reviewed,
(3) Medication errors, if applicable, are reviewed.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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
Sep 09, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.