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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CRPN4C

FACILITY NAME
NG Nair Place
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
LSEO-ASRP2K
FACILITY ADDRESS
23390 47th Ave
FACILITY PHONE
(604) 532-1003
CITY
Langley
POSTAL CODE
V2Z 2S3
MANAGER
Joslyn Kaiser

INSPECTION DATE
May 10, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
11:15 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
24

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 as part of a routine inspection:
- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting


As part of this routine inspection, a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3-year historical review of the facility's compliance and operation.

Visit the CCFL website at https://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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: During physical walk through of the home observation of many flies in the food prep area; noted 15-17 small flies flying around the kitchen.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: May 24, 2023

STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of 3 staff files found that 1 of 3 staff files does not have evidence of compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Please ensure that the manager has obtained evidence of compliance with the Province's immunization and tuberculosis control programs for each employee.
Date to be Corrected: May 24, 2023

MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: During inspection of the physical facility, no evidence of a recent medication room inspection could be found; the last inspecton was completed in November of 2021.
Corrective Action(s): Please ensure that a supervising pharmacist inspects the areas of the facility where medications will be stored.
Date to be Corrected: May 24, 2023


Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance completing this routine inspection.

Please provide a written response by May 24, 2023 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was reviewed with the staff on site and signed It was then sent with the corresponding risk assessment to the Manager/ Licensee via email.)

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
May 24, 2023

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