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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBOI-AYFRYH

FACILITY NAME
Forglen 5450
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
NGIL-7PCMUD
FACILITY ADDRESS
5450 Forglen Dr
FACILITY PHONE
(604) 435-4110
CITY
Burnaby
POSTAL CODE
V5H 3K7
MANAGER
Elmo Jackson

INSPECTION DATE
April 30, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 www.fraserhealth.ca/residentialcare for:

· Additional resources and
· Links to the Legislation (CCALA & RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # 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
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: Review of 2 weeks of the menu found several instances where only one food group is listed for snack. The manager confirms that a second food group has been added, but it is not yet reflected on the menu. This is a repeat contravention from the 2016 and 2017 inspections.
Corrective Action(s): Ensure that the menu reflects food provided and includes 2 food groups for each snack
Date to be Corrected: June 30, 2018

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of the menu audits found 2 weeks of the spring summer menu, which included 4 instances where the menu did not meet the requirements and no change was completed to the menu.
Corrective Action(s): Ensure that there are menu audits completed for each week of the spring summer and fall winter menus and updates are completed as required when the menu does not meet the Canada Food Guide Requirements
Date to be Corrected: August 31, 2018


Comments

Thank you to the Forglen staff for their assistance with the inspection today.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required

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