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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-CYQULA
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
Davinda Renke / Inderjeet Mann / Flora Kwong
INSPECTION DATE
December 19, 2023
ADDITIONAL INSP. DATE (multi-day)
December 21, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
10:30 AM
DEPARTURE
03:00 PM
ARRIVAL
01:30 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
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/licensed-care-facilities-and-assisted-living-providers#.YrT9QyfMI2w
for:
- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).
Contraventions
Previous Inspection -
Current Inspection -
Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation (CORRECTED DURING INSPECTION): One medication cart and two cupboards that hold expired medications were observed on day one to be unsecured.
Corrective Action(s): Ensure staff comply with the policies and procedures of the Medication safety and advisory committee (MSAC).
Date to be Corrected:
Comments
Licensing would like to thank the staff of Carelife Fleetwood for their time and assistance during this routine inspection.
Action Required by Licensee/Manager
Action Required by Licensing Staff
No action required
No action
required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.