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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-D28TGX

FACILITY NAME
5960 Angus Place
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920058
FACILITY ADDRESS
5960 Angus Pl
FACILITY PHONE
(604) 576-0823
CITY
Surrey
POSTAL CODE
V3S 4W7
MANAGER
Amal Hana

INSPECTION DATE
February 07, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
02:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 as part of a routine inspection:
- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting


As part of this routine inspection, a facility risk assessment tool is completed. The risk assessment includes contraventions 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/residentialcare 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
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of Care Plans for 2 Persons in Care(PICs), determined that 1 PIC is missing 2 monthly weights since admission in July 2024 and the other PIC was missing 1 monthly weight in the last year.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: Feb 22, 2024


Comments

This Licensing Officer would like to thank the Staff for their assistance completing this routine inspection.

A conversation was had around performance reviews, they are now due for all staff; the manager is new to the role and has a plan to complete them in the coming months.

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

(Please note: this inspection report was reviewed with the manager on site and signed. It was then sent to the Manager via email.)

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Feb 29, 2024

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