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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AFPUHL
FACILITY NAME
Kinghaven Treatment Centre		SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
0774002
FACILITY ADDRESS
31250 King Rd		FACILITY PHONE
(604) 864-0039
CITY
Abbotsford		POSTAL CODE
V2T 6C2		MANAGER
Milt Walker
INSPECTION DATE
November 09, 2016		ADDITIONAL INSP. DATE (multi-day)
November 14, 2016		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
11:00 AM		DEPARTURE
04:00 PM		ARRIVAL
09:30 AM		DEPARTURE
03:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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)
Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
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 six care records, two persons in care who were referred from Correction Services of Canada (CSC) did not receive TB results as part of the admission package. It was clarified that the expectation is that it is sent by CSC but is not followed up by Kinghaven staff when they do not receive the documentation.
Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Province's tuberculosis control programs.
Date to be Corrected: December 15, 2016
Comments

The following was discussed with the manager:
Ensure a system is set up food that is provided through companies that do not supply food items with expiry dates.
Satisfaction surveys are completed two times a year, it is recommended that they are completed for each menu to ensure all menus are reviewed. Previously, the two satisfaction surveys are completed over the winter menu session.
Policies and procedures are in the process of review.
Currently the rooms on the main floor do not have privacy screens. The manager will be adding a track and curtains to be able to provide the option of privacy if the person in care chooses.
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
Dec 15, 2016
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.