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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-BCUQFS
FACILITY NAME
NG Nair Place		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
LSEO-ASRP2K
FACILITY ADDRESS
23390 47th Ave		FACILITY PHONE
(604) 872-3502
CITY
Langley		POSTAL CODE
V2Z 2S3		MANAGER
Terry Savenye
INSPECTION DATE
June 04, 2019		ADDITIONAL INSP. DATE (multi-day)
June 05, 2019		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
12:15 PM		DEPARTURE
03:15 PM		ARRIVAL
09:15 AM		DEPARTURE
01:00 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report, please feel free to contact the geographic area Licensing Officer.
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: Review of the facility MAR found that medications were administered but were not signed/initialed for in the MAR.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: July 8, 2019

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the substitution list determined that items substituted are not from the same food group and do not have a similar nutrition value.
Corrective Action(s): Ensure that each menu provides substitutions to be made that are from the same food group and have a similar nutritional value.
Date to be Corrected: July 8, 2019

NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Review of the menu determined that the menu has been altered/changed to meet the persons in care's food preferences. The menu being utilized has not been audited to ensure that it meets the person in cares needs based on the Canada Food Guide and the person in care's nutrition plan.
Corrective Action(s): Ensure that when a menu is changed or altered that it still meets persons in cares nutritional needs based on the Canada Food Guide and the person in care's nutrition plan.
Date to be Corrected: July 8, 2019
Comments

This LO would like to thank the Manger and Staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility.

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
Jul 08, 2019
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.