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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-C9NVCQ

FACILITY NAME
CareLife Fleetwood
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962MN5
FACILITY ADDRESS
8265 159th St
FACILITY PHONE
(604) 598-7200
CITY
Surrey
POSTAL CODE
V4N 5T5
MANAGER
Inderjeet Man / Joe Kovatch

INSPECTION DATE
December 13, 2021
ADDITIONAL INSP. DATE (multi-day)
December 14, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
09:00 AM
DEPARTURE
03:00 PM
ARRIVAL
02:00 PM
DEPARTURE
03:30 PM
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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): The following observations were found:
- PIC's medication was found in the tub room located on the second floor.
- Medication found on the bedside table of a PIC's room. Discussion with the manager confirmed that there is an auditing system in place to ensure medications are safely stored.
Corrective Action(s): Ensure that all medications in the facility are safely and securely stored.
Date to be Corrected: December 20, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: In review of 2 out of 7 person in care's care plan it was observed that for one PIC it did not contain a TB risk assessment form or any documentation in the chart to support that this has been assessed. In review of the second PIC's care plan found that the TB risk assessment form was left blank. Discussion with the manager advised that this would have been assessed prior to admittance and that the chart could have been thinned out however, no evidence was provided at the time of the inspection.
Corrective Action(s): A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: January 13, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: The following observations were found:
- An unlabelled deodorant was found in the tub room located on the unit
- An unlabelled shampoo and conditioner was found on the second floor in the tub room
- A collection of shampoo, shaving cream and conditioner was found in the tub room on the vented unit which appeared to be empty most of which did not have any labels. Discussion with the manager advised that staff may have been collecting them to dispose of them altogether.
Corrective Action(s): Ensure items are labelled or placed in individual containers for PIC.
Date to be Corrected: December 20, 2021


Comments

I would like to thank the team at Carelife Fleetwood for their time and assistance in the completing this inspection. If you have any questions related to this report please feel free to contact me.
Due to infection control practices in place related to COVID-19 prevention, this report was written off-site and is therefore unsigned. The report was reviewed with facility leadership and an email copy was provided. Please submit a written response by January 13, 2022 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jan 13, 2022

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