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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-B5KQHE

FACILITY NAME
11A Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920123
FACILITY ADDRESS
5145 11A Ave
FACILITY PHONE
(604) 943-2581
CITY
Delta
POSTAL CODE
V4M 1Z7
MANAGER
Kulvir Sidhu

INSPECTION DATE
October 15, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
09:30 AM
DEPARTURE
01:30 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 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 - Not Applicable
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: During inspection it was noted that
- 1 chair belonging to a PIC is worn and the material is peeling off the headrest and armrests
- 1 dresser in a PIC's bedroom had four broken drawers and was not able to be opened or closed properly
- The toilet paper holder in 1 bathroom was broken and the wall was damaged where half of the holder was pulled out of the wall
Corrective Action(s): Ensure all equipment and furnishings are maintained in a good state of repair
Date to be Corrected: November 30, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: During inspection it was noted that the vent in 1 bedroom and 1 bathroom were dusty
Corrective Action(s): Ensure all rooms and common areas are maintained in a safe and clean condition
Date to be Corrected: October 29, 2018

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: During review of 4 PIC's Binders it was noted that 2 did not have consent forms completed for medical care in the event of injury or illness. Through discussion with the manager it was confirmed that forms had been sent to the families but had not yet been returned. Manager will follow up with the families in regards to the completion of these consents
Corrective Action(s): Ensure the PIC's have appropriate written consent to call medical care in the event of injury or illness
Date to be Corrected: October 29, 2018


Comments

Thank you to the Staff and Management at 11A house for your support and participation in the routine inspection.

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
Oct 29, 2018

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