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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-B78MTK
FACILITY NAME
Kinghaven Treatment Centre		SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
0774002
FACILITY ADDRESS
31250 King Rd		FACILITY PHONE
(604) 864-0039
CITY
Abbotsford		POSTAL CODE
V2T 6C2		MANAGER
Milt Walker
INSPECTION DATE
December 05, 2018		ADDITIONAL INSP. DATE (multi-day)
December 06, 2018		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
11.25
ARRIVAL
09:00 AM		DEPARTURE
03:00 PM		ARRIVAL
12:00 PM		DEPARTURE
02:15 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.
Care systems reviewed include the following:
Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & Reporting
Resident Bill of Rights
Additional CCALA Sections
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).
Contraventions
Previous Inspection - Contraventions observed on FIR #SCLY-ATKTEM have been corrected except for those noted on supplementary pages.
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Of three randomly selected water sources that are accessible to persons in care, two were found to have a temperature reading over 51 degrees.
Corrective Action(s): Ensure that all water accessible to a person in care is not heated to more than 49 degrees.
Date to be Corrected: 21 Dec 2018

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: Of eight randomly selected bedrooms inspected, three were found to have mattresses with the plastic covering torn or missing completely. Of concern is the foam mattresses cannot be cleaned and sanitized.
Corrective Action(s): Ensure that all furniture used by persons in care is maintained in a good state of repair.
Date to be Corrected: 21 Dec 2018

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Of six employee files reviewed, five had not had a performance evaluation since 2015, or prior. This is a repeat contravention from last year's routine inspection (SCLY-ATKTEM)
Corrective Action(s): Ensure that all employees receive regular employee evaluations in order to ensure they demonstrate the competence required for the duties to which they are assigned.
Date to be Corrected: 21 Dec 2018

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: A review of six care records found that three persons in care were missing immunization records.
Corrective Action(s): Ensure that all persons in care comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: 21 Dec 2018
Comments

The Community Care and Assisted Living Act and pursuant Residential Care Regulations set the minimum standards that must be met by all licensees of licensed care facilities to ensure the health and safety of vulnerable individuals in care. The responsibility rests with Kinghaven Treatment Center to provide for the health and safety needs of all individuals in your care at all times.
This LO would like to thank the staff for their assistance with the inspection.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Dec 17, 2018
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.