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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-BLQV9D

FACILITY NAME
13333 - 20th Avenue
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982205
FACILITY ADDRESS
13333 20th Ave
FACILITY PHONE
(604) 538-1635
CITY
Surrey
POSTAL CODE
V4A 1Z3
MANAGER
Kathy Gerard

INSPECTION DATE
February 12, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
02:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

This is an unscheduled routine inspection conducted with a staff member (as the Manager was not present) 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/long-term-care-licensing#.XUHwhWyos2z 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 except for those noted on supplementary pages.

Observed Violations
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A random review of the medication system indicated for example a PRN (as needed) medication did not have the effect/result noted on the back of the medication administration record.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response to this item by February 21, 2020.

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: A random review of the medication system indicated a medication was expired.
Corrective Action(s): Please ensure medication(s) are returned to the pharmacy if the expiry date on the medication has passed.
Date to be Corrected: Please provide a written response to this item by February 21, 2020.


Comments

Thank you for your time to complete this routine inspection. If there are any questions related to this routine inspection report, please contact your assigned 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
Feb 21, 2020

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