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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-CNKUZY
FACILITY NAME
Creation House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
NGIL-BVHPFT
FACILITY ADDRESS
4103 Irmin St		FACILITY PHONE
(604) 435-9544
CITY
Burnaby		POSTAL CODE
V5J 1X6		MANAGER
Peter Brodnan
INSPECTION DATE
January 30, 2023		ADDITIONAL INSP. DATE (multi-day)
January 17, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:30 PM		DEPARTURE
03:30 PM		ARRIVAL
03:00 PM		DEPARTURE
04:00 PM		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/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: 1). Two full metal panel of backyard fence is missing on the perimeter fence. The staff assisting with the inspection informed the LO that fence will be redone but does not have a definite completion timeline.
2). Scruffs and dent marks are visible on the lower half of several walls in the living room and hallways. Staff assisting with the inspection informed LO that a PIC's wheelchair is causing these on the walls.

Corrective Action(s): Please ensure that the fence and all common areas are maintained in good state of repair,
Date to be Corrected: March 17, 2023

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: 2/8 staffing checklist reviewed did not have the performance review completed last fiscal year. The staff assisting with the routine inspection informed the LO that some performance reviews were not completed with casual staff.
Corrective Action(s): Please ensure that the performance of each employee is reviewed regularly to demonstrate the competence required for their duties.

Date to be Corrected: March 17, 2023
Comments

Thank you to all the staff for their assistance with this inspection. All staffing files will be sighted by Licensing on the next fiscal routine inspection visit.

Should any further clarification or questions arise regarding this report, please contact your Licensing Officer.
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 17, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.