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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-C3MUZU
FACILITY NAME
Archway House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982510
FACILITY ADDRESS
5933 168th St		FACILITY PHONE
(604) 576-2455
CITY
Surrey		POSTAL CODE
V3S 3X5		MANAGER
Bhupinder K. (Vinder) Biln
INSPECTION DATE
May 31, 2021		ADDITIONAL INSP. DATE (multi-day)
June 03, 2021		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6
ARRIVAL
09:30 AM		DEPARTURE
12:00 PM		ARRIVAL
10:30 AM		DEPARTURE
02:00 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/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
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: Review of two persons in care records, determined there was not documentation in place to comply with the Province's immunization and tuberculosis programs.
Corrective Action(s): Ensure all persons admitted comply with the Province's Immunization and tuberculosis control programs.
Date to be Corrected: July 5, 2021
Comments

This inspection was completed with staff and the facility manager.

Licensing officer completed a COVID-19 Prevention Checklist with the site and provided the facility with a blank copy of the checklist to support the facility's COVID-19 readiness. The completed checklist was placed on the facility's physical file.

This inspection report was not signed by the facility manger as it was reviewed with the manager at the time of the inspection and sent via email to the site to reduce the amount of time the licensing officers had to spend on site as per COVID-19 prevention measures.

Licensing to forward FH Tuberculosis and immunization guidelines.
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 05, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.