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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME Archway House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0982510
FACILITY ADDRESS 5933 168th St			FACILITY PHONE (604) 576-2455
CITY Surrey	POSTAL CODE V3S 3X5		MANAGER Bhupinder K. (Vinder) Biln

INSPECTION DATE April 20, 2023	ADDITIONAL INSP. DATE (multi-day) July 06, 2023		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4.25
ARRIVAL 10:25 AM	DEPARTURE 11:20 AM	ARRIVAL 10:00 AM	DEPARTURE 12:45 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

A scheduled 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: - 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 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 (CCALA and 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

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide. Observation: Breakfast menu has at times only 2 food groups from the Canada Food Guide. This is a repeat contravention Corrective Action(s): Please ensure all meals contain at least 3 food groups from the Canada Food Guide Date to be Corrected: July 31, 2023 NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide. Observation: Snack menu does not meet the 2 food groups as described in Canada's Food Guide. This is a repeat contravention Corrective Action(s): Please ensure snack menu meets the requirements. Date to be Corrected: July 31, 2023

Comments

Due to time, the repeat was not signed by the Manager but contraventions was discussed. Report to be sent via email. Licensing would like to thank the staff for their assistance during the inspection. Please provide a written response to the contraventions by July 14, 2023

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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