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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KPRK-CF5LLZ

FACILITY NAME
Sakura House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081380
FACILITY ADDRESS
566 Schoolhouse St
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Bree MacKinnon

INSPECTION DATE
June 01, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1
ARRIVAL
09:30 AM
DEPARTURE
10:30 AM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

A follow up inspection to Routine Inspection # KPRK-CE3P24, dated April 22, 2022 was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
RECORDS AND REPORTING: 39610 - RCR s.91(2)(b) - In respect of a record referred to in this regulation, a licensee must (b) keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request.
Observation: Licensing was unable to determine compliance with staff requirements as documentation was stored across four locations. Seven out of seven staff files had at least one instance of missing or expired documentation related to the following regulations: RCR s.43(1)(a) An employee with a valid first aid and CPR certificate is immediately accessible to PICs; RCR s.44(1)(a) Employees responsible for food preparation/service have necessary experience, competence & training; RCR s.86(b) A record of staff’s character references must be kept; RCR s.86(c) A record of staff’s compliance to the immunization and TB control program must be kept.
Corrective Action(s): Ensure records are maintained in a location that can be retrieved by CCFL on request.
Date to be Corrected: June 10, 2022


Comments

This Licensing Officer would like to thank the manager and human resources for their assistance. This inspection was completed via virtual meeting with review of HR electronic files.

RCR s.43(1)(a) regarding First Aid and CPR training was discussed as this item was identified in Routine Inspection # KPRK-CE3P24. The manager identified proof of valid training is stored with her and can be provided at a later time.

Please provide a response to Licensing by June 10, 2022 as to how the identified items in this report will be addressed.

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
Jun 10, 2022

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