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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-B9LRRC

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
February 21, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:00 AM
DEPARTURE
01:30 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report, please feel free to the area Licensing Officer.

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: 31240 - RCR s.21(a) - A licensee must ensure that all furniture and equipment for use by persons in care (a) meet the needs of the persons in care.
Observation: Discussion with the manager determined that one person in care (PIC) requires to be weighed more frequently due to their health concerns. It was determined that a floor scale was purchased by the PIC as the tub scale provides an inconsistent weight and the PIC is uncomfortable when being weighed regularly.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care meets the needs of the persons in care.
Date to be Corrected: March 21, 2109

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: Review of the care plan for one person in care (PIC) determined that there is ongoing wound care but this is not captured in the care plan.
Corrective Action(s): Ensure that care plans are complete.
Date to be Corrected: March 21, 2019


Comments

This LO would like to thank the Program Coordinator and Staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility.

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

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
Mar 21, 2019

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