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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CMCU7W
FACILITY NAME
Banff Place		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
NGIL-BYYTVG
FACILITY ADDRESS
105 - 3755 Banff Ave		FACILITY PHONE
(604) 299-3083
CITY
Burnaby		POSTAL CODE
V5G 3Z9		MANAGER
Loreta Tsang
INSPECTION DATE
December 22, 2022		ADDITIONAL INSP. DATE (multi-day)
December 28, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
12:45 PM		DEPARTURE
02:50 PM		ARRIVAL
03:20 PM		DEPARTURE
03:35 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). 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

Residential Care Regulation
Community Care and Assisted Living Act
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: Facility PIC bathroom has on on-going renovation but no submission and acceptance from Licensing of PICs health and safety plan.
Corrective Action(s): A licensee must not make any structural change to a community care facility unless the licensee first submits to a medical officer a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Date to be Corrected: January 11, 2022
Comments

Thank you to all the staff for their assistance and cooperation with the completion of this routine inspection.
The findings were discussed with the facility leadership while the licensing officer was on site and on the phone.
The copy of the report and risk assessment were provided via email.

Please submit a written response to this routine inspection to Licensing by January 11, 2023.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jan 11, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.