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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-ARLUHM
FACILITY NAME
Grant St. East		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782160
FACILITY ADDRESS
2364 Grant St		FACILITY PHONE
(604) 864-2205
CITY
Abbotsford		POSTAL CODE
V2T 2M7		MANAGER
Louise Duck
INSPECTION DATE
September 27, 2017		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
01:15 PM		DEPARTURE
04:00 PM		ARRIVAL
DEPARTURE
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)
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: No menu substitutions have been documented since June 2017.
Corrective Action(s): Ensure records of menu substitutions are retained.
Date to be Corrected: October 27, 2017
Comments

Licensing would like to acknowledge:
- staff are in the process of documenting one person in care's personal inventory
- the manager will monitor the temperature of one fridge to ensure it's temperature is within the appropriate safe temperature zone.
- Staff are involved in revising the fall/winter menu to ensure persons in care preferences are considered while meeting the requirements of the Canada Food Guide, while ensuring practicality of all staff preparing each menu item.

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
Oct 27, 2017
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.