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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-C36RUT
FACILITY NAME
11A Home		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920123
FACILITY ADDRESS
5145 11A Ave		FACILITY PHONE
(604) 943-2581
CITY
Delta		POSTAL CODE
V4M 1Z7		MANAGER
Marzena Orlinska
INSPECTION DATE
May 19, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:30 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 & 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 -
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: Three bathroom sink temperatures were taken, 2 were over 49C. One was registered at 54C, second at 50C. The hot water registered at 54C is sink most often used by staff but also at times used by PIC.
Corrective Action(s): Please ensure the hot water that is accessible ot PIC is no more than 49C.
Date to be Corrected: June 14, 2021

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: One of the PIC bedroom, two walls have areas where paint has been removed and some drywall is evident. The Manager stated that the whole facility is scheduled for painting.
Corrective Action(s): Please ensure all rooms are in good state of repair.
Date to be Corrected: June 30, 2021
Comments

All Policies and Procedures and Care Plans have been reviewed and updated.
Due to the COVID Pandemic this report was written offsite but discussed with the Manager at the time of the inspection, copy will be sent.
Please provide a written response to how the coded violations will be addressed by May 28, 2021.
Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.