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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CHJQ2E

FACILITY NAME
Primrose Centre for Community Living
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
PNEL-8A2PKD
FACILITY ADDRESS
4807 Georgia St
FACILITY PHONE
(604) 946-0401
CITY
Delta
POSTAL CODE
V4K 2T1
MANAGER
Kevin Reid

INSPECTION DATE
August 22, 2022
ADDITIONAL INSP. DATE (multi-day)
August 26, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:30 AM
DEPARTURE
01:30 PM
ARRIVAL
11:30 AM
DEPARTURE
01:30 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 - Contraventions observed on FIR # have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: In the upper level, the following was noted:
- a bedroom closet door was not secured to the railing,
- a hole in the wall was noted to 1 person in care's suite.
Corrective Action(s): Please ensure all rooms are maintained in a good state of repair.
Date to be Corrected: September 23, 2022


Comments

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

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. 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
Sep 23, 2022

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