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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-CM9P93

FACILITY NAME
13333 - 20th Avenue
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982205
FACILITY ADDRESS
13333 20th Ave
FACILITY PHONE
(604) 538-1635
CITY
Surrey
POSTAL CODE
V4A 1Z3
MANAGER
Kathy Gerard

INSPECTION DATE
December 08, 2022
ADDITIONAL INSP. DATE (multi-day)
December 15, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
09:35 AM
DEPARTURE
10:05 AM
ARRIVAL
10:00 AM
DEPARTURE
01:40 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Random selection of Policies and Procedures indicates last review being completed 2018, 2019 and May 2021. Licensing was provided the processes for review and revision of Policies and Procedures.
Corrective Action(s): Please ensure Policies and Procedures ae reviewed and if required revised at least once a year.
Date to be Corrected: February 6, 2023

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of the weekly menu shows there are times the breakfast menu does not contain at least 3 food groups from the Canada Food Guide.
Corrective Action(s): Please ensure all meals contains at least 3 food groups from the Canada Food Guide.
Date to be Corrected: January 31, 2023

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Review of the weekly menu indicates that snack menu at time are limited in it's nutritional value as well does not contain at least 2 food grops as described in Canada's Food Guide.
Corrective Action(s): Please ensure snacks are nutritious and contain at least 2 food groups from the Canada Food Guide.
Date to be Corrected: January 31, 2023

RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: Review of PIC records indicates that immunization status is unavailable.
Corrective Action(s): Please ensure records are complete.
Date to be Corrected: January 16, 2023


Comments

Licensing discussed during review of staff files, that there must be at least one staff person working on shift who responsibility includes preparation and handling of food to have their Food Safe certification.
Leadership stated that a reportable incident was submitted to Licensing, review indicates that it was not reported, the process was not completed. Licensing provided the Online Reporting information bulletin.
This inspection was discussed with leadership during the inspection.
Licensing would like to thank the staff for their assistance during the inspection.
Licensing forwarded the Employee Immunization Form, Person In Care Immunization record form
Please forward a written response to the contraventions by December 30, 2022

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Dec 30, 2022

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