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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-D28Q2M

FACILITY NAME
CRESST
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
0782527
FACILITY ADDRESS
33720 McDougall Ave
FACILITY PHONE
(604) 870-7583
CITY
Abbotsford
POSTAL CODE
V2S 1W4
MANAGER
Gurpreet Sohi

INSPECTION DATE
February 06, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.5
ARRIVAL
09:30 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

This is a unscheduled routine inspection 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 the 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/licensed-care-facilities-and-assisted-living-providers#.YrT9QyfMI2w 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.

Observed Violations
No violations were found during the inspection.

Comments

Persons in care records/Care plans:
- For example two persons in care immunization forms, part B at the very bottom is a section "reviewed by" and "date" that were not completed. Recommendation to ensure forms are completed in their entirety.
- The site assesses upon admission if a person in care has any oral/dental and/or nutrition related concerns. The site is in process of revising their forms to include this information. When responding to this routine inspection report, please provide an update on when it is anticipated this will be completed by.

Policies and Procedures:
- The site is in the process of reviewing and/or revising policies and procedures. When responding to this routine inspection report, please provide an update on when it is anticipated this will be completed by.

Staffing:
- The site is in the process of putting together a staff checklist that takes into account the legislative requirements as noted in the Residential Care Regulation. The Patient Care Coordinator anticipates this will be completed by end of February 2024.

Medication:
- Overall it appears PRN (as needed) medications have a result/effectiveness/outcome documented. A few entries did not have an outcome documented and specifics were provided to the Patient Care Coordinator at time of the inspection. The Patient Care Coordinator stated at the time of the inspection that an e-mail will be sent to the nursing staff to remind them to document the effectiveness. As the overall system appeared to be thorough, no contravention was assigned.

Thank you for the time taken to complete this inspection. If there are any questions related to this routine inspection report, please contact the Licensing Officer that completed the routine inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Feb 29, 2024

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