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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-B8XUF9

FACILITY NAME
Crawford Manor ("A")
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
LSEO-AFXNT7
FACILITY ADDRESS
10008 128th St
FACILITY PHONE
(604) 255-0340
CITY
Surrey
POSTAL CODE
V3T 2Y9
MANAGER
Ken Falconer

INSPECTION DATE
January 31, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

ROUTINE INSPECTION REPORT

An unscheduled routine inspection 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 the inspection.

The following areas were reviewed:

o Licensing
o Physical Facility
o Staffing
o Policies and Procedures
o Care and Supervision
o Hygiene and Communicable Disease Control
o Medication
o Nutrition and Food Services
o Programming
o 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 noncompliance identified during the routine inspection, and a 3 year 'historical' review of the facility's compliance and operations.

Please visit the Community Care Facilities Licensing website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/

[For additional resources, and links to the legislation (CCALA and RCR).]

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: In review of 1 person in care's medication administration record, 6 medication's were not initialed or documented to confirm if the medication was administered as required.
Corrective Action(s): Please ensure employees comply with the medication policies and procedures.
Date to be Corrected: February 15, 2019

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: In review of 2 person's in care charts, records of the risk for tuberculosis and required testing were not completed.
Corrective Action(s): Please ensure that for all persons admitted to the facility there is a record for risk to tuberculosis and evidence of screening if required.
Date to be Corrected: March 1, 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: In review of 1 person in care's weight records, it was noted that weight was not recorded for a period of 3 months in 2018.
Corrective Action(s): Please ensure that person's in care are weighed at least once each month. If the person in care refuses to be weighed, please document in the weight chart the reason.
Date to be Corrected: March 01, 2019


Comments

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

This report was reviewed and discussed with the Manager.

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
Feb 15, 2019

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