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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CMKPYW
FACILITY NAME
Fletcher 1		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081368
FACILITY ADDRESS
12062 Fletcher St		FACILITY PHONE
(604) 463-7118
CITY
Maple Ridge		POSTAL CODE
V2X 6K9		MANAGER
Veerinder Mann
INSPECTION DATE
December 29, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:00 AM		DEPARTURE
12:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
5
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 1 of 5 PIC's health care records found that one PIC did not have evidence tuberculosis screening.
Corrective Action(s): Ensure that all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: January 29, 2023
Comments

I would like to thank the team at Fletcher 1 for their time and assistance in the completing this inspection. Please submit a written response by January 29, 2023 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
This inspection report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jan 29, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.