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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

JKAS-CCAQ8P

FACILITY NAME Grant St. East		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0782160
FACILITY ADDRESS 2364 Grant St			FACILITY PHONE (604) 864-2205
CITY Abbotsford	POSTAL CODE V2T 2M7		MANAGER Angela Poulton

INSPECTION DATE March 04, 2022	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2.75
ARRIVAL 10:45 AM	DEPARTURE 01:30 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 3

Introduction

Routine Inspection Report An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 - Policies and Procedures - Care and Supervision - Hygiene and Communicable Disease Control - Medication - Nutrition and Food Services - Program - Records and Reporting As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions 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

POLICIES AND PROCEDURES: 33090 - RCR s.51(4) - A licensee must display a copy of the emergency plan in a prominent place in the community care facility. Observation: During the physical inspection it was noted that the Emergency Plan was not posted in the facility. Corrective Action(s): Ensure that a copy of the emergency plan is in a prominent place. Date to be Corrected: April 1, 2022. POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year. Observation: During file review it was noted that the Policies and Procedures (Program Services Manual) was last reviewed in May of 2020. Corrective Action(s): Ensure that policies and procedures are reviewed and, if necessary, revised at least once each year. Date to be Corrected: April 1, 2022

Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection. Please provide a written response by April 1, 2022 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report. (Please note: due to infection control practices related to COVID-19 prevention, this inspection report was reviewed with the Manager, written off-site and forwarded to the Licensee. Therefore no signature was obtained.)

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Apr 01, 2022

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