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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-C22N8X

FACILITY NAME
5984 - 191A Street
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920056
FACILITY ADDRESS
5984 191A St
FACILITY PHONE
(604) 574-7229
CITY
Surrey
POSTAL CODE
V3S 7N1
MANAGER
Cheryl Coueffin

INSPECTION DATE
April 12, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
09:50 AM
DEPARTURE
12:10 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 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
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Restraint is required to ensure the health and safety of PIC, written agreement/consent by the medical practitioner is unavailable.
Corrective Action(s): Please ensure the medical practitioner has provided written agreement for restraints.
Date to be Corrected: May 12, 2021

POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Yearly review of Policies and Procedures has not been conducted
Corrective Action(s): Please ensure Policies and Procedures are reviewed at least once a year
Date to be Corrected: May 14, 2021

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of the menu indicates there are at times the meals do not contain at least 3 food groups from the Canada Food Guide. Examples include, French Toast with juice and banana, grilled cheese with mushroom soup, water with wieners and beans.
Corrective Action(s): Pleae ensure the meals contain at least 3 food groups.
Date to be Corrected: May 10, 2021

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Based on review of the menu, the snacks do not contain at least 2 food groups. Menu includes cookies, ice cream.
Corrective Action(s): Please ensure that at least 2 nutritious snack with each snack containing at least 2 food groups from the Canada Food Guide
Date to be Corrected: May 10, 2021

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: There were at times the substitutions did not come from the same food group such as waffles for sausages, toast for ham/steak.
Corrective Action(s): Please ensure that substitutions are made from the same food group and with similar nutritional value
Date to be Corrected: May 10, 2021


Comments

All of the PIC were in home at the time of inspection along with 3 staff. Licensing would like to thank all the staff for their assistance during the inspection.
Due to COVID pandemic, the report was not written on site but all of the coded violations was discussed with the Manager at the time of the inspection.
Please provide a written to response to how the coded violations will be addressed by May 6, 2021

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
May 04, 2021

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