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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-CMZLMA

FACILITY NAME
Forglen 5452
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
NGIL-7PBVL2
FACILITY ADDRESS
5452 Forglen Dr
FACILITY PHONE
(604) 435-4110
CITY
Burnaby
POSTAL CODE
V5H 3K7
MANAGER
Nitesh Naidu

INSPECTION DATE
January 05, 2023
ADDITIONAL INSP. DATE (multi-day)
January 09, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
12:00 PM
DEPARTURE
01:30 PM
ARRIVAL
12:00 PM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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
· Hygiene and Communicable Disease Control
· Physical Facility
· Medication
· Staffing
· Nutrition and Food Services
· Policies and Procedures
· Program
· Care and Supervision
· 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 CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XXbB7myos2w for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)
Visit the CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: 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: The exterior screen/storm doors are broken and will be of concern when fresh air circulation is needed without the risks of allowing bugs access inside the facility and during the warmer months.

Corrective Action(s): Please ensure that all common areas are maintained in a good state of repair.
Date to be Corrected: January 31, 2023

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31820 - RCR s.36(1)(c) - A licensee must provide outside activity areas that have (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather.
Observation: The covered area outside for activities is not sufficient and reasonable amount of shelter from sun and inclement weather is not provided.
Corrective Action(s): Ensure that reasonable amount of shelter from sun and inclement weather is available measuring at least 1.5m2 of space for each person in care
Date to be Corrected: February 15, 2023

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: 1/7 staff on the checklist provided had expired First Aid/CPR certification
Corrective Action(s): Please ensure staff implement all the policies appropriately.
Date to be Corrected: January 31, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): A bowel of leftover food was found stored uncovered and unlabeled in the fridge. The staff assisting with the routine inspection informed the LO that the policy is to label and cover leftovers before putting them in the fridge.

Corrective Action(s): Please ensure that all food are safely stored and labeled.
Date to be Corrected:


Comments

Thank you to all the staff for their assistance with this inspection.

Should any further clarification or questions arise regarding this report, please contact your Licensing Officer.

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
Jan 20, 2023

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