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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-CX6RDZ
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
Raniel Alberastine
INSPECTION DATE
November 01, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:35 AM		DEPARTURE
01:15 PM		ARRIVAL
DEPARTURE
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 https://www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & 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
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 MAR indicates that effectiveness(PRN) information was not documented on a consistent basis as per the requirement.
Corrective Action(s): Please ensure staff comply with the MAR at all times.
Date to be Corrected: November 2, 2023 (as needed)
Comments

Discussion around the weight scale used, leadership recognizes that at times the reading may not be accurate.
The summer menu has been update, discussion ensuring both the winter and summer menu be updated to ensure all the requirements are met.
Licensing would like to thank the staff for their assistance during the inspection.
This report was reviewed by leadership and copy will be emailed.
Please provide an action plan to address the coded contravention by November 8, 2023.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Nov 08, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.