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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-AXBPNY
FACILITY NAME
CareLife Fleetwood		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962MN5
FACILITY ADDRESS
8265 159 St		FACILITY PHONE
(604) 598-7200
CITY
Surrey		POSTAL CODE
V4N 5T5		MANAGER
Kate Hille (Birch, Maple, Alder, Willow, Arbutus) & Inderjeet Mann (Cedar, Cypress, Spruce, Pine)
INSPECTION DATE
March 27, 2018		ADDITIONAL INSP. DATE (multi-day)
March 29, 2018		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
10:30 AM		DEPARTURE
04:30 PM		ARRIVAL
10:00 AM		DEPARTURE
11:00 AM		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 Care Plans
o Programming
o Records and Reporting

Please note: A review of the Food Services Department was not completed on this inspection. A follow-up inspection to review food service's will be completed at a later date with assistance of the Licensing Dietitian.

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: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: During the inspection of the physical facility, in one unit it was noted that laundry machines were available to family members for the washing of person's in care personal items. Laundry detergent was located above the machine on a shelf, and not safely secured.
Corrective Action(s): Please ensure that all cleaing agents and chemical products are safely secured.
Date to be Corrected: March 29, 2018

RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation: In review of a care plan for a person in care who has an aggrement in place for the use of a restraint, there was no information noted in the care plan regarding the duration of the restraint use or the monitoring of the person in care during the restraint.
Corrective Action(s): Please ensure that all persons in care who have aggrements in place for a restraint, that information is noted in the care plan to provide direction to staff regarding how the person in care will be monitored during the restraint use.
Date to be Corrected: April 30, 2018
Comments

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

This report was reviewed and discussed with the Manager.

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
No action requiredNo action required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.