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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME Brookswood Court		SERVICE TYPES 120 Mental Health	FACILITY LICENSE # 0801030
FACILITY ADDRESS 3830 200th St			FACILITY PHONE (604) 534-3996
CITY Langley	POSTAL CODE V3A 1K2		MANAGER Sharan Gill

INSPECTION DATE January 29, 2019	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.5
ARRIVAL 09:30 AM	DEPARTURE 12:30 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 contact the geographic area Licensing Officer.

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: 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: Review of the MAR determined that there were blank spaces on the MAR. Facility medication policies state that either a initial was required to show administration of a medication or a number to determine why a medication was not administered. Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee. Date to be Corrected: February 25, 2019

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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