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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

WCLK-AF3Q5L

FACILITY NAME Christel House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0904186
FACILITY ADDRESS 11753 82nd Ave			FACILITY PHONE (604) 597-1286
CITY Delta	POSTAL CODE V4C 2C3		MANAGER Patti Kimball

INSPECTION DATE October 25, 2016	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 09:00 AM	DEPARTURE 01:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

A scheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s(LO) observations, review of facility records and information provided by facility staff at the time of the inspection.

As part of the Routine Inspection a 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.

A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights.

Visit CCFL website at www.fraserhealth.ca/residential care for additional resources and links to legislation (CCALA and RCR)

Contraventions

Previous Inspection - Contraventions observed on FIR #WCLK-A2VRNA have been corrected except for those noted on supplementary pages.

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: Hot water temperature was measured at 2 sinks and both measured above 51 degrees Celsius.
Corrective Action(s): Please adjust and monitor water temperature to ensure it does not pose a burn risk to persons in care.
Date to be Corrected: October 25, 2016

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 hardwood floors in the living room and hallway have patches where the flooring finish has been scratched away with the constant movement of furniture exposing the unfinished wood. The exposed wood has a rough texture and potential for splintering. In addition the integrity of the wood may be compromised further as cleaning agents may absorb into the unfinished wood.
Corrective Action(s): This is considered to be a repeat contravention. The wooden floor appears to have been damaged further and is in need of repair and/or replacement.
Date to be Corrected: Please submit a compliance plan as to how this contravention will be addressed.

CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation (CORRECTED DURING INSPECTION): Licensing audited 2 person in care's weight records and 1 person did not have a weight amount or reason for not being weighed documented from January - May 2016. Weights for October 2016 were documented.
Corrective Action(s): Please ensure if weights are not obtained that staff document the reason. During this inspection the Manager made a notation in the staff communication book to inform staff of the requirement.
Date to be Corrected: November 1, 2016

Comments

Licensing requests a written response be submitted on or before November 10, 2016 describing how the above noted contraventions have been appropriately addressed. For contraventions where a compliance plan has been requested please include a time for when compliance will be met.
A follow-up inspection confirming compliance to the CC&ALA and RCR may be conducted after the compliance plan has been received by Licensing.

Copies of the inspection report and the Risk Assessment Tool were reviewed, discussed, and provided to the Manager. If you have any further questions regarding this report please contact your Licensing Officer (business card provided).

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Nov 10, 2016

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