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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KPRK-CF7R9U
FACILITY NAME
Cook Avenue		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081755
FACILITY ADDRESS
21181 Cook Ave		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Kathy Westhaver
INSPECTION DATE
June 03, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
09:30 AM		DEPARTURE
11:30 AM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

A follow up inspection to Routine Inspection # KPRK-CEYLA5, dated May 26, 2022 was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: An employment policy was not implemented in the case of one staff.
Corrective Action(s): Ensure policies and procedures are implemented by employees.
Date to be Corrected: June 17, 2022

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: Two out of nine staff did not have record of performance reviews. One staff file was without record of any performance review and the other had none within the past four years.
Corrective Action(s): Ensure record of staff performance reviews are kept.
Date to be Corrected: June 17, 2022
Comments

This Licensing Officer would like to thank the manager and human resources for their assistance.

Please provide a response to Licensing by June 17, 2022 as to how the identified items in this report will be addressed.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
(Please note: this inspection report was written off-site and later reviewed and forwarded to the Licensee. Therefore no signature was obtained.)
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
Jun 17, 2022
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