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-AQNN7X
FACILITY NAME
Peace Portal Seniors Village		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9SW5
FACILITY ADDRESS
15441 16th Ave		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Glenn Hocking
INSPECTION DATE
August 28, 2017		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.25
ARRIVAL
09:15 AM		DEPARTURE
10:30 AM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# CHILDREN ENROLLED
72
Introduction

This is a follow-up inspection completed with the General Manager to the routine inspection report #CRAU - APNU5L (completed on July 27, 2017).
Contraventions
Previous Inspection - Contraventions observed on FIR #CRAU - APNU5L have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: One staff's file that was reviewed during the routine inspection that did not have a copy of their diploma, certificates as per Section 37 (1)(d) of the Residential Care Regulation is in the process of being addressed. The General Manager stated the staff will have this addressed by the end of the week September 1, 2017.
Corrective Action(s): Please ensure where applicable all staff have copies of their diploma, certificates as required by Section 37 (1)(d) of the Residential Care Regulation.
Date to be Corrected: Please let the writer know when the staff has obtained a copy of their diploma/certificate.
Comments

Tuberculosis and Immunizations for persons in care:

- A review of one private pay person in care's chart indicated their tuberculosis assessment and immunizations is on file, however for the immunizations, part B to be completed by the employer is not complete. Please note: The tuberculosis and immunization forms are from the updated Tuberculosis and Immunization Guideline that the writer e-mailed to the Director and Care and copied the General Manager on July 27, 2017. Recommendation to complete part B of the immunization form. The General Manager stated they will ensure part B is completed for all private pay persons in care. Please let the writer know when this addressed for all private pay persons in care.

First aid kit monthly audits forms:

- The General Manager showed the writer the first floor/main floor audit that will be kept with the first aid kit. The audit was completed for August 2017. The General Manager stated all other first aid kits will have an audit form that goes with each kit as well and the first aid kits will be reviewed on a monthly basis.

Nutrition and Food Services Education:

- The 2016 in-service schedule was seen by the writer, however there are no participation records that go with each in-service.
- For 2017 the last in-service was completed on April 12, 2017 and the one previous to that was on March 29, 2017.
- The General Manager stated that the next in-service for 2017 will take place in September 2017.
- The General Manager reinforced with the Dietitian on August 23, 2017 to keep comprehensive records including participation records for in-services they provide.

- The General Manager stated other in-services are completed as well and will touch base with the Director of Care regarding this and will get back to the writer. Please forward all other in-services after touching base with the Director of Care.

Thank you for your time to complete today's inspection. If there are any questions regarding this report, please contact your 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
Sep 15, 2017
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.