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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-B3FUYQ
FACILITY NAME
Peace Portal Seniors Village		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9SW5
FACILITY ADDRESS
15441 16th Ave		FACILITY PHONE
(604) 535-2273
CITY
Surrey		POSTAL CODE
V4A 8T8		MANAGER
Glenn Hocking
INSPECTION DATE
August 08, 2018		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7.25
ARRIVAL
09:00 AM		DEPARTURE
04:45 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
70
Introduction

This is a routine inspection conducted with the General Manager and Interim Director of Care 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. Total time of inspection was 7.25 hours and 0.50 hours to review resources with the Interim Director of Care (a separate report was completed for this).

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/residential-care-licensing#.W2CWtTpKipp 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
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A review of the care planning system indicated for two charts (specifics of examples given) whereby the record of care for oral/dental care for various shifts throughout the day are not initialed by the staff. The Interim Director of Care stated they will reinforce this with staff the importance of documenting thoroughly.
Corrective Action(s): Please ensure there is regular monitoring of the physical environment, the care and services provided by it to ensure the requirements of the Act and Residential Care Regulation are being met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: Specific examples were given as to the dates items were substituted however there is nothing noted as to what was substituted. In addition, specifics were given as to a few items that were substituted however it is not for example, protein for protein, etc.
Corrective Action(s): Please ensure menu substitutions are thoroughly documented and similiar products are substituted (e.g., protein for protein).
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: There is no food monitoring schedule usually in-place from the audits and more manual. In addition, the nutrition care plan audit is from the year 2016 and there does not appear to be recent audit of this. Please ensure nutrition audits are completed as per the schedule throughout the year and completed accordingly.
Corrective Action(s): Please ensure nutrition audits are completed as per the schedule that is in-place.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
Comments

Activities of Daily Living documents:

In discussion with the Interim Director of Care for the 2nd floor all the ensuite washrooms have the Activities of Daily Living documents accessible. For the first floor the Activities of Daily Living documents are not in the ensuite washrooms, but the documents are accessible in a binder for the care staff. The Interim Director of Care stated they will be working to ensure consistency in process with the Activities of Daily Living documents. Please let the writer know your plan to address this.

Staff files:

The staff files that were reviewed have paper loosely stored in them. Recommendation to ensure the documentation in the staff files is securely in-place.

Thank you for your time to complete today's inspection. If there are any questions, 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
Aug 24, 2018
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.