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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-AXVQ7T
FACILITY NAME
NG Nair Place		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
LSEO-ASRP2K
FACILITY ADDRESS
23390 47th Ave		FACILITY PHONE
(604) 872-3502
CITY
Langley		POSTAL CODE
V2Z 2S3		MANAGER
Renay Bajkay
INSPECTION DATE
April 16, 2018		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
10:00 AM		DEPARTURE
02:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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 the area Licensing Officer.
Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Review of 4 person in care (PIC) care plans found that all 4 recreation plans were older than one year. Discussion with the Manager and staff determined that the new recreation staff started today.
Corrective Action(s): Ensure that all PIC care plans are reviewed on an annual basis.
Date to be Corrected: May 16, 2018

CARE AND/OR SUPERVISION: 34770 - RCR s.81(4)(c) - A licensee must ensure that (c) to the extent reasonably practical, persons in care participate in the review and modification of their own care plans.
Observation: A review of 1 of 4 person in care (PIC) care plans found no recovery plan. Discussion with the Manager determined that recovery plans are in the process of being completed and all will be completed by May 1, 2018.
Corrective Action(s): Ensure that care plans are complete.
Date to be Corrected: May 1, 2018

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: Review of 4 person in care (PIC) care plans did not identify compliance with the Province's immunization control program.
Corrective Action(s): Ensure that PIC immunization records are complete.
Date to be Corrected: May 16, 2018
Comments

This LO would like to thank the Manger and 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
May 14, 2018
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.