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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-AFZRYM

FACILITY NAME
Creekside Withdrawal Management Centre
SERVICE TYPES
125 Substance Use
201 Child & Youth Residential
FACILITY LICENSE #
BHAN-6J7QU9
FACILITY ADDRESS
Removed at operator's request
FACILITY PHONE
Removed at operator's request
CITY
Surrey
POSTAL CODE
Removed at operator's request
MANAGER
Removed at operator's request

INSPECTION DATE
November 24, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

ROUTINE INSPECTION REPORT

A routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 the inspection.

The following areas were reviewed:

o Licensing
o Physical Facility
o Staffing
o Policies and Procedures
o Care and Supervision
o Hygiene and Communicable Disease Control
o Medication
o Nutrition and Food Services
o Programming
o Records and Reporting

As part of this Routine Inspection, a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes noncompliance identified during the routine inspection, and a 3 year 'historical' review of the facility's compliance and operations.

Please visit the Community Care Facilities Licensing website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/

[For additional resources, and links to the legislation (CCALA and 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: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: In the 'Youth Section' it was noted that bathtubs did not have a slip resistant mat on the bottom of each bathtub/shower.
Corrective Action(s): Please ensure that all bathtubs have a slip resistant material or mat available for use by the persons in care.
Date to be Corrected: November 25, 2016


Comments

The following was discussed with the Manager and PCC:

A copy of the revised 'Tuberculosis Testing and Immunization Guideline' was provided to the manager. The guide states that prior to admission, all persons in care admitted to a licensed community care facility will be assessed for the possible presence of tuberculosis. Assessment is performed using an established set of criteria, as outlined in the guide. An exception to this process is for persons in care who require 'emergency admission', whereby an assessment prior to admission would impede the admission process, example being a 'Detox Centre' such as Creekside. In this situation, the TB and Immunization Guideline directs the facility to assess the person in care at the time of admission for the possible presence of active TB. The guide provides a list of signs and symptoms of active TB. To ensure compliance with the Province's immunization and tuberculosis control program, please ensure that persons in care are assessed on admission for the presence of active TB (signs and symptoms) and a record of this is on file.

On inspection of the outdoor patio attached to the Youth Section, it was observed that a partial 'short' concrete wall can obstruct the ability of staff to supervise the youth when outdoors. The manager stated that this is a concern, and options have been discussed to remove the wall. It was noted that RCR 22(1)(c) states that a licensee must ensure common areas are maintained in a safe condition. It was recommended that a plan be developed to address the wall, as staff have confirmed that this could be a health and safety issue.

Information was provided regarding the new regulations that came into effect for youth residential sites, RCR 24 - Helpline for Children. It was discussed that on admission, youth are advised and provided with contact information for the Helpline for Children, and the youth are provided with access to communications equipment if needed. A copy of RCR 24 was provided with the Inspection Report.

This LO would like to thank the Manager and the PCC for their time and assistance in completing this routine inspection.

This report was reviewed and discussed. A copy of this report and the noted additional resources will be mailed to the facility.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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
Dec 08, 2016

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