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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

NTJN-BKLPWP

FACILITY NAME Chelsey House 2003 Ltd		SERVICE TYPES 120 Mental Health	FACILITY LICENSE # MLAO-7J4U55
FACILITY ADDRESS 4544 216th St			FACILITY PHONE (604) 530-0352
CITY Langley	POSTAL CODE V3A 2M4		MANAGER Deborah Howie

INSPECTION DATE January 07, 2020	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3
ARRIVAL 10:00 AM	DEPARTURE 01:00 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 & 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) If you have any questions regarding this report, please feel free to the area Licensing Officer.

Contraventions

Previous Inspection - Contraventions observed on FIR #NTJN-B9RT6J have been corrected.

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

Observed Violations

POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year. Observation: Review of the facilities policies and procedures determined that a few polices still contained old language and not include the new language. Discussion with the Manager stated that all policies are currently in use and reviewed but some still need the language to be updated. Corrective Action(s): Ensure that all policies and procedures at least once each year. Date to be Corrected: February 10, 2020

Comments

This LO would like to thank the Manger and Staff for their time and assistance in completing this routine inspection. This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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

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