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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-D22MME

FACILITY NAME
Firth Residence
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
DANN-A5XVZ3
FACILITY ADDRESS
Removed at operator's request
FACILITY PHONE
Removed at operator's request
CITY
Abbotsford
POSTAL CODE
Removed at operator's request
MANAGER
Removed at operator's request

INSPECTION DATE
February 01, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
09:30 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
11

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & 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 -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: 4 of 4 PIC records reviewed, the PICs had given consent to be weighed monthly, and 3 of 4 had been weighed upon admission, but not again, and the 4th person had not been weighed at all. This is a repeat contravention from 2023.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: Feb 15, 2024


Comments

Discussed during inspection:
-Sections of legislation regarding MSAC - LO will e-mail to manager
-Emergency food supply
-monitoring of water temps
-Menu audits and food groups per serving - LO will send a bulletin RE: food and nutrition sections of the RCR
-No updates regarding the proposed kitchen remodel


It is requested that a written response be submitted on or before February 15th describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

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
Feb 15, 2024

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