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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-CELL9X

FACILITY NAME
5984 - 191A Street
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920056
FACILITY ADDRESS
5984 191A St
FACILITY PHONE
(604) 574-7229
CITY
Surrey
POSTAL CODE
V3S 7N1
MANAGER
Cheryl Coueffin

INSPECTION DATE
May 20, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.25
ARRIVAL
10:30 AM
DEPARTURE
12:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled follow-up 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

Visit the CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The grab bar in the washroom is rusty
Corrective Action(s): Ensure equipment used by PIC's is maintained in a good state of repair
Date to be Corrected: June 3 2022

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: At the time of inspection the TB records for the PIC's were unable to be located so there was no record that the PIC's meet the provinces TB control programs
Corrective Action(s): Ensure records of TB status are available and PIC's meet the requirements
Date to be Corrected: June 3, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation:
Fridge and freezer temperatures for the kitchen are not being monitored or documented
Food in the freezer is stored in the freezer in ziploc bags that are not labelled
Corrective Action(s): Ensure food is safely stored
Date to be Corrected: May 20, 2022


Comments

Thank you to the staff and management for their time and support during the routine inspection

Due to technical difficulties the report was unable to be completed on site, report was emailed to the facility

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
May 20, 2022

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