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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-CEAUKR
FACILITY NAME
Celebration & Rainbow Manor		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982449
FACILITY ADDRESS
10130 159A St		FACILITY PHONE
(604) 582-0790
CITY
Surrey		POSTAL CODE
V4N 2P8		MANAGER
Evangeline Ballestra
INSPECTION DATE
May 10, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.75
ARRIVAL
09:30 AM		DEPARTURE
01:15 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
7
Introduction

This is a unscheduled routine inspection 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 the inspection.

The following areas were reviewed:

- 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 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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XUHwhWyos2z for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).
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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The hot water temperature was measured randomly and the following are the measurements:

* 1st floor/main floor tub room sink measured at 50.2 degrees Celsius.
* 2nd floor sink in bathroom adjacent to the kitchen measured at 49.5 degrees Celsius.

During the inspection, the Maintenance Staff was called and came on-site adjusting the temperature at the hot water tank. In addition, the plumbing company that installed the hot water regulating device was called who will come on-site to address the hot water temperature.
Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: Please let the writer know by May 11, 2022 how this has been addressed.
Comments

Policies and Procedures:
* The Resident Abuse policy under "The Person in Charge and Administrator" under point #2 states - Adult Care Facilities and informs Licensing Coordinator. In discussion with the Manager, point #2 is a continuation of point #1 and this will be adjusted accordingly and Licensing Coordinator will be replaced with Licensing Officer. Please let the writer know when this will be completed by. As the policies and procedures are similar to the adjacent licenced home, the policies and procedures will be updated where required for both homes.
*The Reportable Incidents Policy on page 5 of 7 states aggression between individuals (i.e., persons in care) is reportable to CLBC (funder) only. Further in the same policy it makes reference to aggression between individuals being reportable to Community Care Facilities Licensing (CCFL). Please ensure the policy clearly defines which reportable definitions are reportable to which agency (i.e., CLBC and CCFL), so staff are clear as to what is reportable. Please let the writer know when this will be completed by.
* Communicable Disease Policy has a list of reportable diseases in BC from 2013. On May 10, 2022 the Licensing Officer e-mailed to the Manager the most current list of reportable diseases in BC from 2018. In addition, the policy states to send a reportable incident report to CCFL within 24 hours. Recommendation to change 24 hours to "after the outbreak has been declared over" given information will change during an outbreak such as number of persons in care affected and so on. Please let the writer know when this will be completed by.
Due to the Covid-19 pandemic, the findings were reviewed and discussed with the Manager at the time of the inspection. This inspection report, and risk assessment was written off-site and then emailed on May 10, 2022 to the Manager for review and to finalize the report and risk assessment once they were in agreement to the wording. As a result of the pandemic, signature for the Manager is not included. If there are further questions related to this routine inspection, please contact your Licensing Officer.
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 13, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.