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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-AQYTYD
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
Sara Abbott
INSPECTION DATE
September 07, 2017		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
12:30 PM		DEPARTURE
04:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604-949-7714 or by email at nicholas.birch@fraserhealth.ca

Contraventions
Previous Inspection - Contraventions observed on FIR #SCLY-ADMSR8 have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: During the inspection it was noted that 1 PIC had medications that are not being provided by a pharmacy. 11 medications are being bought over the counter by the family and provided to the facility, they are being stored in their original store-bought container.
Corrective Action(s): Please ensure that all medications are packaged by a pharmacist. Please provide a response to Licensing regarding this contravention.
Date to be Corrected: October 30 2017


Comments
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.