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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-BFAMDK
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
August 21, 2019		ADDITIONAL INSP. DATE (multi-day)
August 22, 2019		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
10:30 AM		DEPARTURE
05:00 PM		ARRIVAL
01:30 PM		DEPARTURE
02:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

ROUTINE INSPECTION REPORT

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (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:

o Licensing
o Physical Facility
o Staffing
o Policies and Procedures
o Care and Supervision
o Hygiene and Communicable Disease Control
o Medication
o Nutrition and Food Services
o Programming
o 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 noncompliance identified during the routine inspection, and a 3 year 'historical' review of the facility's compliance and operations.
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: 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: During inspection of the second floor, it was noted that water temperatures exceeded 49 degrees in 2 bedrooms.
Corrective Action(s): Please ensure that water accessible to persons in care is not heated to more than 49 degrees celsius.
Date to be Corrected: September 12, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Inspection of the physical facility found a box of laundry detergent in a unsecured cabinet.
Corrective Action(s): Please ensure any cleaning agents or chemical products are secured safely in a designated storage area.
Date to be Corrected: Corrected at time of inspection.

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: During inspection of the 2nd floor, in 1 person in care's bedroom, a medication was found on the bedside table. The manager explained that this medication was likely brought into the facility by a contact person.
Corrective Action(s): Please ensure that all medications are safely and securely stored.
Date to be Corrected: August 23, 2019
Comments

This LO would like to thank the Managers and staff for their assistance in completing this routine inspection.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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
Sep 20, 2019
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.