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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-BE4P5G
FACILITY NAME
12698 - 25th Avenue		SERVICE TYPES
104 Specialized Residential Care Home
FACILITY LICENSE #
0904182
FACILITY ADDRESS
12698 25th Ave		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Kawaldeep Bal
INSPECTION DATE
July 15, 2019		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
0.83
ARRIVAL
10:10 AM		DEPARTURE
11:00 AM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
4
Introduction

This is a follow-up inspection conducted with the Program Coordinator/Manager to routine inspection report # CRAU - BCKQ4W.
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: The staff signing sheet in the medication administration record book was noted with a few staff that did not complete this signing sheet. Specifics given during the inspection. The Manager has a plan to address this.
Corrective Action(s): Please ensure the care and services provided by the home are monitored regularly to ensure that the requirements of the Act and Residential Care Regulation are being met.
Date to be Corrected: Please provide a written plan as noted in this report when this will be addressed by.

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A random review of the medication administration records indicated a medication was not initialed for on the front of the medication administration record and specifics of this were provided at the time of the inspection.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the Medication Safety and Advisory Committee.
Date to be Corrected: Please provide a written plan as per the timeline noted in this report as to when this will be addressed by.

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Fire drills are to be completed once a month. The last drill is from May 2019 and there is no drill for June 2019.
Corrective Action(s): Please ensure all staff implement the policies and procedures.
Date to be Corrected: Please provide a written plan as per the timeline noted in this report as to when this will be addressed by.
Comments

Thank you for your time to complete this inspection.

If there are any questions related to 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
Jul 19, 2019
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Click here for a description of each "Category" of violation displayed.