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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-CZZNF7
FACILITY NAME
Evergreen Hamlets at Fleetwood		SERVICE TYPES
130 Long Term Care
140 Community Living
150 Acquired Injury
FACILITY LICENSE #
NKAR-CEXLM4
FACILITY ADDRESS
8382 156th St		FACILITY PHONE
(604) 597-7906
CITY
Surrey		POSTAL CODE
V3S 3R7		MANAGER
Jennifer Fisher
INSPECTION DATE
January 31, 2024		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.5
ARRIVAL
10:00 AM		DEPARTURE
04:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
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/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: 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: Water temperatures measured at 7 water sources found that temperatures exceed 49 degrees at 2 sources, with the highest being 54.5 degrees. These water sources were accessible to Persons in care.
Corrective Action(s): Ensure that water temperatures do not exceed 49 degrees.
Date to be Corrected:


Comments

Upon inspection of the care community's physical facility it was observed to have worn flooring and several areas where walls had minor damage and paint was scratched off. These deficiencies did not appear to present a risk to the persons in care. In discussion with the leadership it was understood that a plan is being developed to address these deficiencies and to improve the physical facility overall.

Thank you to the staff for their time and support in completing this inspection. Please contact your Licensing Officer if you have any questions or concerns.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.