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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-D4LRM8

FACILITY NAME
5984 - 191A Street
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920056
FACILITY ADDRESS
5984 191A St
FACILITY PHONE
(604) 574-7229
CITY
Surrey
POSTAL CODE
V3S 7N1
MANAGER
Cheryl Coueffin

INSPECTION DATE
April 23, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
01:30 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

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 thfis 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 as part of a routine inspection:
- 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: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of 4 Persons in Care(PICs) Medication Administration Records(MARs) determined that 4 of 4 PICs MARs do not show evidence of results for PRN medications. It was determined that PIC A's MAR does show results for 2 of 11 PRN medications, PIC B's MAR does not show results for 3 of 23 PRN medications, PIC C's MAR does not show results for 3 of 7 PRN medications and PIC D's MAR does not show results for 5 of 15 PRN medications.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 7, 2024


Comments

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

Please provide a written response by May 7, 2024 indicating the corrective actions taken and/or time line with plan for compliance with legislative requirements.

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 manager over the phone, it was signed by staff and a copy was provided to the Manager via email)

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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