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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-ATXT65

FACILITY NAME
Bakerview Court
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982907
FACILITY ADDRESS
18919 62A Ave
FACILITY PHONE
(604) 576-1255
CITY
Surrey
POSTAL CODE
V3S 8S4
MANAGER
Amanda Trudeau-Rai

INSPECTION DATE
December 08, 2017
ADDITIONAL INSP. DATE (multi-day)
December 11, 2017
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6
ARRIVAL
09:00 AM
DEPARTURE
01:00 PM
ARRIVAL
01:15 PM
DEPARTURE
03:00 PM
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)
If you have any questions regarding this report feel free to contact me email at naomi.tanakajesson@fraserhealth.ca.

Contraventions
Previous Inspection - Contraventions observed on FIR #MMAE-AKUU4G 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Inspection of the facility found the following:
-Missing light covers for room and closet light, one missing outlet cover, one missing lamp shade in one PIC's room
-Two PIC's bedrooms had hole in walls
-Main bathroom cabinetry had peeling finish on 4 cabinet doors
-Kitchen missing a cabinet door
-Carpet is showing wear and has staining throughout

Discussion with the Manager determined that the one PIC bedroom is an ongoing concern, as the damage is caused by the PIC. It was confirmed that there is an ongoing repair plan in place to address the above identified concerns.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 11, 2017

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the substitution list found that "leftovers" was substituted for the main meal. It was discussed with the Manager that substitution should indicate what the meal is to determine if they are from the same good group and have a similar nutrition value.
Corrective Action(s): Ensure the substitutions clearly state what the food groups are in the meal. If the meal is leftovers from another day, please indicate what the leftover meal was ex. Chicken substituted for pork.
Date to be Corrected: January 11, 2017


Comments


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
Jan 11, 2018

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