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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JBAY-CARUJ6

FACILITY NAME
Fletcher 1
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081368
FACILITY ADDRESS
12062 Fletcher St
FACILITY PHONE
(604) 463-7118
CITY
Maple Ridge
POSTAL CODE
V2X 6K9
MANAGER
Veerinder Mann

INSPECTION DATE
January 14, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:30 AM
DEPARTURE
02:10 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
5

Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), the Residential
Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include:
Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & 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 historical review of the facility’s compliance and operation.

Visit the CCFL website at 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: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: An inspection of the physical facility found the following:

1) An approximately 3 meter length of siding on the south side of the facility was observed to be hanging down which requires reattachment or replacement.
2) A drawer in the kitchen on the left side of the stove was observed to have its finish peeling off (approximately 15 cms in length) which requires repair or replacement.
3) A fence gate at the north side of the yard near the front of the facility was observed to be detached from its fence post and needs to be reattached.
4) A fire extinguisher was observed to be detached from its wall bracket in the south hall and was sitting on the floor (according to management, maintenance had already been called and the facility was expecting them to arrive that afternoon to reattach the extinguisher).
5) A cover for a baseboard heater in the family room was observed to be loose and requires proper reattachment. Additionally, the end caps on the same baseboard heater were observed to be separating and require reattachment.
This is a repeat contravention.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 21, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: A hatch door on the floor in the office which leads to the crawl space was observed to be raised up at one end (one end is not flush with the floor and sticks up approximately 2 cms) making the floor uneven which is a potential tripping hazard. Additionally, an inspection of the facility grounds found several gardening items (some which appeared to be broken) including a wire cone (typically used to support tomato plants) left outside on the south side of the facility which requires removal or storage. This is a repeat contravention.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: February 4, 2022

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: A review of medication administration records found three instances where the effectiveness of a PRN medication was not recorded as per policy.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: January 21, 2022


Comments

Please submit a written response by January 31, 2022 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.
This inspection report was not signed as it was reviewed with management over the telephone and sent via email to the site to reduce the amount of time the licensing officer had to spend on site as per COVID-19 prevention measures.

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 31, 2022

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