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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JFUR-CU3RGS

FACILITY NAME
Amica White Rock
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
TBIU-B38N9X
FACILITY ADDRESS
15333 16th Ave
FACILITY PHONE
(778) 545-8800
CITY
Surrey
POSTAL CODE
V4A 1R6
MANAGER
Tamara Quinn

INSPECTION DATE
July 25, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.5
ARRIVAL
09:45 AM
DEPARTURE
02:00 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 as part of a routine inspection:
- Licensing
- Physical Facility
- 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.

Visit the CCFL website at https://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
STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: 2 of 6 staff files reviewed did not contain food safe certificates.
Corrective Action(s): A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certifications or other evidence of the person's training and skills.
Date to be Corrected: 8-August-2023

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: 2 signatures on 2 separate days were missing for double signing areas of the Narcotics audit sheet in 1 of the medication cabinets.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory comittee
Date to be Corrected: 8-August-2023

RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: of 6 files reviewed, 2 did not contain TB status for residents in care.
Corrective Action(s): A licensee must keep, for each person in care, a record showing the followin information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Date to be Corrected: 8-August-2023

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: 1 of 6 resident files reviewed was missing a consent form.
Corrective Action(s): A licensee mist have, and keep with each person in care's record, consent in writing from the person in care or a parent or a representative of teh person in care (a) to call a mendical practioner, nurse practitioner or ambulane in case of accident or illness.
Date to be Corrected: 8-August-2023

RECORDS AND REPORTING: 39440 - RCR s.86(d) - A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Observation: 1 of 6 staff files reviewed was missing performance reviews.
Corrective Action(s): A licensee must keep the following records in respect of each employee: (d) a record of any performance review made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Date to be Corrected: 8-August-2023


Comments

Thank you for your time and assistance with completing this inspection.

Please submit a written response by August 8, 2023 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

(Please note: this inspection report was reviewed with the Manager, written on-site and forwarded to the Licensee.)

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
Aug 08, 2023

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