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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Holmberg House Hospice
SERVICE TYPES
110 Hospice
FACILITY LICENSE #
TBIU-9UAPLB
FACILITY ADDRESS
32780 Marshall Road
FACILITY PHONE
(604) 613-4201
CITY
Abbotsford
POSTAL CODE
V2S 1J7
MANAGER
Teresa Armstrong

INSPECTION DATE
November 21, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
09:00 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

Ascheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s(LO)
observations, review of facility records and information provided by facility staff at the time of the inspection.

As part of the Routine Inspection a 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. As this facility was licensed in April 2016, the history reviewed would include the application process and limited history since the date of the licence being issued.

A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights.

Visit CCFL website at www.fraserhealth.ca/ccfl for additional resources and links to legislation (CCALA and RCR)

Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: The Support Services Manager explained staff are expected to document menu substitutions on a standard form. The form was not available during this inspection to confirm when and if substitutions were made.
Corrective Action(s): Please ensure documentation is kept related to menu substitutions.
Date to be Corrected: November 22, 2016


Comments

Licensing requests a written response be submitted on or before December 9, 2016 describing how the above noted contraventions have been appropriately addressed. A follow-up inspection confirming compliance to the CC&ALA and RCR may be conducted after the written response has been received by Licensing.

Copies of the inspection report and the Risk Assessment Tool were reviewed, discussed, and provided to the 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
Dec 09, 2016

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