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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CMKT7U

FACILITY NAME
Fletcher 2
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081366
FACILITY ADDRESS
12076 Fletcher St
FACILITY PHONE
(604) 463-7444
CITY
Maple Ridge
POSTAL CODE
V2X 6K9
MANAGER
Trisha Rose

INSPECTION DATE
December 29, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
12:00 PM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
5

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 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
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): A review of the medication cabinet found two PRN medications passed expiry date.
Corrective Action(s): Ensure expired medications are returned to the pharmacist.
Date to be Corrected: January 29, 2023

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 1 of 5 PIC's weight charts determined that a weight was not captured for the month of September and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: January 29, 2023


Comments

I would like to thank the team at Fletcher 2 for their time and assistance in the completing this inspection. Please submit a written response by January 29, 2023 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
This inspection report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jan 29, 2023

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