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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-B94PMV

FACILITY NAME
Fraser Supported Community Living
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982393
FACILITY ADDRESS
4723 206A St
FACILITY PHONE
(604) 533-5531
CITY
Langley City
POSTAL CODE
V3A 6N7
MANAGER
Jatinder Aujla

INSPECTION DATE
February 01, 2019
ADDITIONAL INSP. DATE (multi-day)
February 05, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
11:30 AM
DEPARTURE
12:00 PM
ARRIVAL
09:00 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
As part of the 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report, please feel free to contact the geographic area Licensing Officer.

Contraventions
Previous Inspection -
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: Review of the Medication Administration Records (MAR) for 3 of 4 persons in care (PIC); determined that the PRN's records were not complete and the back of the MAR sheet did not provide for an area to record the following: PRN date administered; PRN reason; PRN results; etc. The facility MSAC policy requires this information to be recorded and it was not captured.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 5, 2019

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the menu documentation found a menu substitution list form but no completed menu substitution list. It was determined by the menu that meatballs were on the dinner menu but staff confirmed that the pork chops defrosting in the fridge were for dinner. Staff confirmed that they do not complete the menu substitution list.
Corrective Action(s): Ensure that each menu provides for substitutions to be made that are from the same food group and have a similar nutritional value.
Date to be Corrected: March 5, 2019

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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 the weights for 1 person in care determined that no weight was recorded for December 2018 and no reason was given for the weight not being obtained.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: March 5, 2019


Comments

This LO would like to thank the Staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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
Mar 05, 2019

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