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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Deer Lake House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203596
FACILITY ADDRESS
6098 Sperling Ave		FACILITY PHONE
(604) 520-0656
CITY
Burnaby		POSTAL CODE
V5E 2T9		MANAGER
Tami Short
INSPECTION DATE
May 01, 2023		ADDITIONAL INSP. DATE (multi-day)
May 12, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.25
ARRIVAL
03:30 PM		DEPARTURE
03:45 PM		ARRIVAL
02:00 PM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
3
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). 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 & 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

Residential Care Regulation
Community Care and Assisted Living Act
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: One of 3 persons on care has no evidence of compliance to Province's immunization and tuberculosis control programs on file.
Corrective Action(s): A licensee must require all person admitted to community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 29, 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: One of 3 persons in care have no monthly weight recorded on file. The person in care is requiring a special weighing scale which is not available in the facility.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: May 29, 2023
Comments

Upon inspection found a hole on the wall in the dining area and another one in the hallway approximately measures 5 x 4 inches and the basement toilet tank has no cover. These were already reported and waiting for the maintenance personnel to come as per staff.

Thank you to all staff for their assistance and cooperation of this routine inspection.
The findings were discussed with the facility leadership and signed while licensing officer was on site.
A copy of the report and risk assessment was provided via email.

Please submit a written response to this routine inspection to Licensing by May 29, 2023.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
May 29, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.