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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CD3UDX

FACILITY NAME
Delta View Life Enrichment Centre
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTAC
FACILITY ADDRESS
9321 Burns Dr
FACILITY PHONE
(604) 501-6700
CITY
Delta
POSTAL CODE
V4K 3N3
MANAGER
Tracy Nikkel

INSPECTION DATE
March 30, 2022
ADDITIONAL INSP. DATE (multi-day)
March 31, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9
ARRIVAL
10:30 AM
DEPARTURE
03:30 PM
ARRIVAL
10:00 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

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: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: In review of six employee files, it was noted that two employees have not had a recent performance review. One employee had a performance review in 2018 (4 years ago), and the other employee did not have a record of any performance reviews.
Corrective Action(s): Please ensure that the performance of each employee is reviewed both regularly and as directed by facility policy.
Date to be Corrected: Please provide a response to Licensing by April 15, 2022.

STAFFING: 32270 - RCR s.44(2) - A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is (a) a nutrition manager with membership in the Canadian Society of Nutrition Management, (b) a person who is eligible to be a member of the Canadian Society of Nutrition Management, or (c) a dietitian.
Observation: In discussion with staff, it was confirmed that membership in the Canadian Society of Nutrition Management (CSNM) has not been obtained for the employee who is responsible for supervising the preparation and delivery of food. It was also confirmed that the employee is not currently eligible for membership to the CSNM.
Corrective Action(s): Please provide a response to Licensing as to how the noted contravention will be addressed.
Date to be Corrected: Due date April 15, 2022.


Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection.

Please provide a response to Licensing as to how the noted contraventions will be addressed by April 15, 2022.

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 forwarded to the Licensee)

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
Apr 15, 2022

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