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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-CXTUKE
FACILITY NAME
Fleet Street Group Home		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
LBAA-8CFSTG
FACILITY ADDRESS
2994 Fleet St		FACILITY PHONE
(604) 944-0408
CITY
Coquitlam		POSTAL CODE
V3C 3R8		MANAGER
Dorine Lata
INSPECTION DATE
November 22, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.5
ARRIVAL
01:30 PM		DEPARTURE
02:50 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 & 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: 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: Upon inspection of 2 water sources that are accessible to persons in care, where measures at 59 degrees Celsius.
Corrective Action(s): Please ensure that water is not heated to more than 49 degrees Celsius.
Date to be Corrected: November 29, 2023
Comments

Thank you for your assistance in completing this inspection.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Nov 29, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.