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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CFGQKD

FACILITY NAME
Crestlene Lodge Ltd
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
MLAO-6VQVVA
FACILITY ADDRESS
11660 86th Ave
FACILITY PHONE
(604) 591-3773
CITY
Delta
POSTAL CODE
V4C 2X6
MANAGER
Mario Tengco

INSPECTION DATE
June 09, 2022
ADDITIONAL INSP. DATE (multi-day)
June 10, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
01:00 PM
DEPARTURE
02:00 PM
ARRIVAL
11:00 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

ROUTINE INSPECTION

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.

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: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Inspection of the laundry room that is used by persons in care determined that there is no slip resistant floor surface such as a mat in close proximity to the washing/dryer machines.
Corrective Action(s): Please ensure a slip resistant floor surface is available in the laundry room.
Date to be Corrected: July 4, 2022

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: In review of the menu, several afternoon and evening snacks were noted to have only 1 food group.
Corrective Action(s): Please ensure that each menu provides at least 2 food groups for each snack.
Date to be Corrected: July 4, 2022

RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection 77(3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: In review of internal facility incident reports, it was determined that 6 incidents had occurred in the past 2 years that did meet the definition of a reportable incident and require submission to the medical health officer (Licensing). Licensing was not notified of these incidents.
Corrective Action(s): Please ensure that if a person in care is involved in a reportable incident that Licensing is notified in the form and in the manner required.
Date to be Corrected: July 4, 2022


Comments

This LO would like to thank the manager and staff for their assistance in completing this routine inspection.

Please provide a response to Licensing by July 4, 2022 as to how the noted contraventions will be addressed.

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
Jul 04, 2022

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