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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
DBED-AW2V9Q

FACILITY NAME
Grant St. West
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782159
FACILITY ADDRESS
2375 Grant St
FACILITY PHONE
(604) 864-6448
CITY
Abbotsford
POSTAL CODE
V2T 2M8
MANAGER
Louise Duck

INSPECTION DATE
February 16, 2018
ADDITIONAL INSP. DATE (multi-day)
February 19, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
09:00 AM
DEPARTURE
12:00 PM
ARRIVAL
09:00 AM
DEPARTURE
10:00 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), 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
· 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 CCFL website at www.fraserhealth.ca/your_environment/ccfl for:
· Additional resources, and
· Links to the Legislation (CCALA and CCLR)

Contraventions
Previous Inspection - Contraventions observed on FIR #KDHL-AK8VE9 have been corrected.
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Water temperature was taken around 1100 in one bathroom and kitchen. Both temperatures measured 59 Degrees
Corrective Action(s): To ensure water temperatures do not go above 49 Degrees
Date to be Corrected: Feb 23rd, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Bookshelf approximately 6 feet high in one P.I.C bedroom was not maintained in a safe manner.
Corrective Action(s): To ensure that furniture is secured safely against wall to prevent risk of falling onto P.I.C in the event of an earthquake.
Date to be Corrected: Feb 23, 2018

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Two items stored outside in freezer were not dated nor labelled.
Corrective Action(s): To ensure all food stored is dated and labelled appropriately and regular food rotation is being implemented.
Date to be Corrected: Feb 23, 2018


Comments

The facility self identified that fencing outside had been damaged due to ice storm in Jan of 2018. A requisition has been forwarded to head office.
Three policy and procedures were reviewed during this visit: Critical Incident Policy; Risk Management and Medication Safety and Pharmacy Act.
Due to technical difficulties unable to provide signatures. Hard copy was reviewed and received by manager.

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 23, 2018

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