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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-AUPS2A

FACILITY NAME
13330 - 20A Avenue
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982206
FACILITY ADDRESS
13330 20A Ave
FACILITY PHONE
(604) 538-1587
CITY
Surrey
POSTAL CODE
V4A 9K2
MANAGER
Gigi Rojas

INSPECTION DATE
January 04, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:45 AM
DEPARTURE
01:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
4

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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.

Please visit the Community Care Facilities Licensing (CCFL) website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:

* Additional resources, and
* Links to the legislation (i.e., CCALA and 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
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: A random review of the physical plant indicated that the hot water temperature at the sink in the shower room measured at 52.1 degrees Celsius. The Manager phoned BC Housing to address this issue.
Corrective Action(s): Please ensure all sinks, showers/tubs accessible to persons in care is maintained at 49 degrees Celsius or lower.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

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: A random review of the policies and procedures required by the Residential Care Regulation indicated for example the Nutrition and Menu Planning policy was last reviewed/modified in October 2015. Please review the Residential Care Regulation Section 85 (2) and please ensure all the policies and procedures noted/listed are reviewed and/or revised once a year and the date(s) are reflected on those policies and procedures.
Corrective Action(s): Please ensure required policies and procedures as per the Residential Care Regulation are reviewed and/or revised once a year.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A random review of one person in care's records/care plan indicated their nutrition satisfaction survey and Nutrition Care Plan Checklist were completed in 2016. The Manager stated they will ensure this is updated to ensure it is current.
Corrective Action(s): Please ensure nutrition audits are completed on a regular basis to ensure they are current.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report for a response.


Comments

Nutritional Care Plans:

A random review of one of the person in care's records/care plan indicated there is documentation related to nutrition and a consult from the HSCL (Health Services Community Living) Dietitian. The Manager advised the writer that the nutritional status of the person in care does not require further intervention by the HSCL Dietitian. The Manager was in the process of reviewing these documents and indicating no changes to the nutritional care plan. Please ensure this is reviewed for all the persons in care and please let the writer know when this is addressed.

Thank you for your time to complete today's inspection. If there are any questions regarding this report, please contact your Licensing Officer.

Please note:

The writer was not able to sign this report using the tablet. The writer had the Manager review this report and sign and then the writer printed two copies which the writer signed. The writer provided the Manager one copy of the report that the writer signed and one copy will stay on Community Care Facilities Licensing's file.

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
Jan 12, 2018

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