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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Elgin House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982079
FACILITY ADDRESS
2942 144th St
FACILITY PHONE
(604) 541-0944
CITY
Surrey
POSTAL CODE
V4P 1P6
MANAGER
Tarundeep Kaur

INSPECTION DATE
January 09, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:00 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted 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 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. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Review of the four week menu shows there are at times snacks only contains one food group from the Canada Food Guide. As well some of the food are lacking in nutrition.
Corrective Action(s): Please ensure snacks are nutritious and contain at least 2 food groups.
Date to be Corrected: February 28, 2023

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: The menu substitution record indicates several times where the substitution were not made from the same food group with a similar nutritional value.
Corrective Action(s): Please ensure substitutes are made in compliance with the Legislation.
Date to be Corrected: January 13, 2023


Comments

Licensing would like to thank the staff for their assistance during the inspection.
Please provide a written response to the contraventions by January 16, 2023.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jan 16, 2023

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.