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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

SYUU-CCBQR8

FACILITY NAME Fair Haven Burnaby Lodge		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # 3200045
FACILITY ADDRESS 7557 Sussex Ave			FACILITY PHONE ()
CITY	POSTAL CODE		MANAGER Joy Parsons

INSPECTION DATE March 01, 2022	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 1.5
ARRIVAL 10:20 AM	DEPARTURE 11:20 AM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Follow-up					# OBSERVED IN CARE

Introduction

An unscheduled inspection follow up inspection to determine compliance with the Residential Care Regulation (RCR), Community Care and Assisted Living Act (CCALA) and any relevant Director of Licensing Standards of Practice (DLSOP). Evidence for this inspection was based on information provided by staff, review of facility records and licensing officer's observation at the time of the inspection. The purpose of the inspection was to review the implementation of the action plan received in response to the routine inspection dated August 17, 2021. All areas that are still outstanding can be found in the Observation, Correction and Action Section of this report.

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: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair. Observation: The ceiling of the spa room located on the lower level has not been addressed. Corrective Action(s): Please ensure the ceiling tile is in good state of repair. Date to be Corrected: April 12, 2022 STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned. Observation: The staff performance review was not completed at the time of the inspection. Licensing was made aware that they are in the process of completing the required performance review. Corrective Action(s): Please ensure staff performance review is completed Date to be Corrected: March 21, 2022

Comments

Due to the Infection prevention control measures, the report was written off site but was discussed the time of the inspection. Please forward the written response by March 14, 2022 confirming the completion dates for the outstanding items. Licensing would like to thank the staff for their assistance during the time of the inspection.

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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