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
CRAU-BLBQ87

FACILITY NAME
13330 - 20A Avenue
SERVICE TYPES
104 Specialized Residential Care Home
FACILITY LICENSE #
0982206
FACILITY ADDRESS
13330 20A Ave
FACILITY PHONE
(604) 538-1587
CITY
Surrey
POSTAL CODE
V4A 9K2
MANAGER
Kawaljot Bal

INSPECTION DATE
January 30, 2020
ADDITIONAL INSP. DATE (multi-day)
January 20, 2020
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
08:15 AM
DEPARTURE
12:00 PM
ARRIVAL
09:00 AM
DEPARTURE
09:15 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

Introduction

An unscheduled routine inspection was initiated on January 20, 2020 however there was an emergency the home was dealing with and the writer completed the remainder of the inspection on January 30, 2020 with the Manager 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 the inspection.

The following areas were reviewed:

- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- 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 (C.C.A.L.A. and R.C.R.).

Contraventions
Previous Inspection - Not Applicable
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: A review of the physical plant indicated the back door to the backyard has several scuff/black marks and the Manager explained this is due to wheelchairs, etc.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

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: A random review of one person in care's chart/records indicated no tuberculosis screening was documented. Please refer to the Tuberculosis and Immunization Guideline for persons in care that the Licensing Officer previously sent.
Corrective Action(s): Please ensure all persons in care have tuberculosis screening completed.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

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: A random review of one person in care's chart/records indicated there was one weight not documented for. Specifics were provided during the inspection.
Corrective Action(s): Please ensure all persons in care are weighed on a monthly basis and that this is documented. If for example the weight scale is not functioning, a person in care refuses to be weighed, etc, please ensure this is documented accordingly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A review of the audits indicated for example the menu audit for week 5 (winter) as noted on the computer program "Sharevision" that the initial audit was completed in November 2017 and clicking on the actual audit it refers to a modified date of January 2019. The Manager stated a modified date is put in after reviewing the initial audit that was completed. Please ensure audits are completed on a regular basis and given the previous audit was modified in early January 2019, it now has been over 1 year since the last review.
Corrective Action(s): Please ensure all applicable nutrition audits are being completed for the home and are being completed on a regular basis please.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.


Comments

Physical Plant:

- The tree that was to be cut which created an uneven pathway has now been cut down and the pathway needs to be made even as discussed with the Manager. Please ensure health and safety measures continue until such time the pathway is made even.

Thank you for your time to complete today's routine inspection. If there are any questions related to this routine inspection report, please contact your assigned 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 07, 2020

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