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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Aster House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982269
FACILITY ADDRESS
15625 Aster Rd		FACILITY PHONE
(604) 363-7343
CITY
Surrey		POSTAL CODE
V4A 1Y4		MANAGER
Dwayne McInnes
INSPECTION DATE
September 27, 2023		ADDITIONAL INSP. DATE (multi-day)
October 06, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.5
ARRIVAL
10:40 AM		DEPARTURE
12:15 PM		ARRIVAL
10:30 AM		DEPARTURE
12:20 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/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
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: Downstairs shower stall observed corners and up along areas where drywall was shown and piece was missing. Leadership is aware and has put forth request
Corrective Action(s): Please ensure common areas are in good state of repair
Date to be Corrected: November 6, 2023

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation (CORRECTED DURING INSPECTION): Review of the menu indicates snack is missing the requirement of having at least 2 nutritious snacks whenever fruit and jello is included.
Corrective Action(s): Please ensure requirement is met
Date to be Corrected: corrected during October 12th visit
Comments

The inspection was completed on October 12th at Milieu Head office as the computer was could not be accessed on the October 6th inspection date.
Licensing would thank all of the staff for their assistance during the inspection
Oral Hygienist conducted an inspection in the summer as provided by staff but documentation of such could not be found, during the October 12th visit, Licensing was informed it was March 2023 when visit was done, the facility has requested another visit to ensure care plan is available.
Please provide an action plan to the coded contravention by October 20. 2023
The inspection report will be emailed.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Oct 20, 2023
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Click here for a description of each "Category" of violation displayed.