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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-CVNLTK
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
September 14, 2023		ADDITIONAL INSP. DATE (multi-day)
September 15, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
10:10 AM		DEPARTURE
10:40 AM		ARRIVAL
10:00 AM		DEPARTURE
11:30 AM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include:
· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records & 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).
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice.
Observed Violations
No violations were found during the inspection.
Comments

Inspection was conducted over two days. Day one, arrived at the home to only one staff and one PIC present, the rest are on an outing. As PIC was getting ready to go out to their own outing, a tour of the physical facility was conducted only. Day two LO was able to conduct the routone inspection.
Standards of food safety was discussed as staff currently take "Caring for food safe" which is re-taken every 5 years.

Thank you for your time assisting with todays inspection
Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.