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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

CRAU-B3MQNR

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 August 14, 2018	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.25
ARRIVAL 09:45 AM	DEPARTURE 01:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED 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 (RCR), 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: - 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 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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2CWtTpKipp for: - Additional resources, and - Links to the legislation (C.C.A.L.A. and R.C.R.).

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

CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan. Observation: A random review of one person in care's care planning indicated they do have recreation activities that they attend, however there doesn't appear to be an assessment completed for the recreation/leisure activities and from the assessment would be a recreation care plan developed. The writer discussed this with the Manager and the writer will forward resources to the Manager to guide them in developing person in care specific recreation care plans. Corrective Action(s): Please ensure there is a recreation care plan in-place for each person in care. Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.

Comments

Medication Administration Binder: * There are signatures not noted for staff and in discussion with the Manager the writer was advised the staff noted are not regular staff except for one. The Manager will look into this and ensure signatures/dates, etc are documented where required. Please let the writer know when this is addressed. Emergency equipment such such emergency lighting and fire extinguishers not noted with the current service date. For example outside the tub room is a fire extinguisher and emergency lighting in the hallway with a service date of August 11, 2018. The Manager will contact the fire contracted company to get this addressed. Please keep the writer updated on this as to how it is addressed. Thank you for your time to complete today's inspection. If there are any questions related to this report, please contact your Licensing Officer.

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 Sep 04, 2018

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