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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

AROE-CBBTBN

FACILITY NAME Brookside Lodge		SERVICE TYPES 130 Long Term Care 150 Acquired Injury	FACILITY LICENSE # TGAL-9KZQCZ
FACILITY ADDRESS 19550 Fraser Hwy			FACILITY PHONE (604) 530-6595
CITY Surrey	POSTAL CODE V3S 6K5		MANAGER Allison Kesler

INSPECTION DATE February 04, 2022	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4.25
ARRIVAL 10:00 AM	DEPARTURE 02:15 PM	ARRIVAL	DEPARTURE	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/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: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair. Observation: Inspection of the physical facilities noted - Door damages caused by wheelchairs - water staining on the bathroom roof in the front entrance - mold in the spa room - wall damage in the tub room - mdf molding in shower is water damaged Corrective Action(s): Ensure rooms and common areas are maintained in a good state of repair Date to be Corrected: Feb 18, 2022 STAFFING: 32260 - RCR s.44(1)(b) - A licensee must ensure that employees responsible for the preparation and delivery of food (b) receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques. Observation: review of 6 staff files noted that 3 were missing evidence of food service education Corrective Action(s): ensure all employees who deliver food services have ongoing education Date to be Corrected: Feb 18, 2021

Comments

Thank you to the staff and management at Brookside Lodge for their support during the routine inspection

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Feb 18, 2022

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