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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CRAPUN

FACILITY NAME
5984 - 191A Street
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920056
FACILITY ADDRESS
5984 191A St
FACILITY PHONE
(604) 574-7229
CITY
Surrey
POSTAL CODE
V3S 7N1
MANAGER
Cheryl Coueffin

INSPECTION DATE
April 27, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.75
ARRIVAL
12:15 PM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
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 (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
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- 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
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 2 Persons in Care(PICs) charts determined that 1 of 2 PICs chart does not show evidence for 4 monthly weights in the last 12 months.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: May 11, 2023


Comments

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

Please provide a written response by May 11, 2023 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 staff on site and signed It was then sent with the corresponding risk assessment to the Manager/ Licensee via email.)

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
May 11, 2023

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