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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CGNT2T
FACILITY NAME
Orion House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982585
FACILITY ADDRESS
20395 42nd Ave		FACILITY PHONE
(236) 558-3241
CITY
Langley		POSTAL CODE
V3A 3A6		MANAGER
Deanne Walsh
INSPECTION DATE
July 21, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
12:45 PM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
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:

- 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: It is noted that the toilet in the shower room has a large crack, approximately 20 to 30 cm in length, in the porcelain on the back/base.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a safe and clean condition.
Date to be Corrected: August 8, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: 3 or 4 Doors/doorways and door trim in the common areas and hallways have deep scrapes and are missing paint.
Corrective Action(s): Ensure that all common areas are maintained in a good state of repair.
Date to be Corrected: August 8, 2022

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: The non slip flooring in both the shower and tub rooms is noted to be visibly dirty and soiled; with a number of areas that appear black.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: August 8, 2022.

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 3 Persons in Care(PIC) charts, 1 of 3 PICs had no evidence of a recorded weight for at least one month in a one year period.
Corrective Action(s): Ensure that PICs are weighed at least once each month.
Date to be Corrected: August 8, 2022
Comments

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

Please provide a written response by August 8, 2022 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

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, written off-site and forwarded to the Licensee. Therefore no signature was obtained.)
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
Aug 08, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.