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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CMYTNE
FACILITY NAME
Fraser Supported Community Living		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982393
FACILITY ADDRESS
4723 206A St		FACILITY PHONE
(604) 533-5531
CITY
Langley City		POSTAL CODE
V3A 6N7		MANAGER
Balwinder Bains
INSPECTION DATE
January 11, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
11:45 AM		DEPARTURE
03:00 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 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.

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: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of 3 employee files, 1 of 3 files did not have evidence of compliance with the provincial immunization and tuberculosis control programs.
Corrective Action(s): Ensure that evidence of compliance with the Provincial immunization and tuberculosis control programs.
Date to be Corrected: Jan 25, 2023

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 2 persons in care(PIC) charts found that 1 of 2 PICs chart did not have evidence of 1 monthly weight over the last 12 months.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: Jan 25, 2023

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: Noted during inspection, no evidence of menu substitution available
Corrective Action(s): Ensure that a record respecting food services: menu and menu substitutions is kept.
Date to be Corrected: Jan 25, 2023
Comments

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

Please provide a written response by January 25, 2023 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

Discussion with the manager regarding 1 item in the upstairs fridge, it appeared to be leftovers in a sealed container, without a date or label on it. Manager states that it belongs to a staff member, and she will follow up with the team to ensure that all items are labelled and dated.

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 staff on site and signed. It was then forwarded with the corresponding risk assessment to the Licensee via email.)
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
Jan 25, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.