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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JFUR-CVNLTF

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
Bobbi Sherman

INSPECTION DATE
September 12, 2023
ADDITIONAL INSP. DATE (multi-day)
September 14, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6
ARRIVAL
09:30 AM
DEPARTURE
01:30 PM
ARRIVAL
09:50 AM
DEPARTURE
10:00 AM
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 as part of a routine inspection:
- Licensing
- Physical Facility
- 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
LICENSING: 30160 - RCR s.11(1)(b) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (b) the most recent routine inspection record made under section 9 (1)(d) of the Act.
Observation (CORRECTED DURING INSPECTION): Most recent Routine Inspection was not on display. This is a repeat contravention.
Corrective Action(s): A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (b) the most recent routine inspection record made under section 9 (1)(d) of the Act.
Date to be Corrected:

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: Observed standing water on the floor of first floor bathroom..
Corrective Action(s): A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Date to be Corrected: 28-Sept-2023

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): A container of bleach was found in a Person in Cares bedroom. Conversation with staff acknowledged that the chemicals should have been identified during room inspection and removed.
Corrective Action(s): A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected:

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Please ensure that staff implement the facilities medication administration process.
Corrective Action(s): In review of medication administration and in discussion with staff, it was confirmed that the effectiveness of PRN medication administered were not consistently documented as per facility policy. This is a repeat contravention
Date to be Corrected: 28-Sept-2023


Comments

Thank you for your time and assistance with completing this inspection.

Please submit a written response by September 28, 2023 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

(Please note: this inspection report was reviewed with the Manager, written on-site and forwarded to the Licensee.)

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
Sep 28, 2023

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