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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-B57Q3T

FACILITY NAME
216A Street
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
TGAL-95RQ8D
FACILITY ADDRESS
8983 216A St
FACILITY PHONE
(604) 293-0284
CITY
Langley
POSTAL CODE
V1M 4C7
MANAGER
Corey Nonis

INSPECTION DATE
October 03, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
10:30 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

A scheduled 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 the area Licensing Officer

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected except for those noted on supplementary pages.
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: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: Inspection found that the downstairs bathtub and the upstairs shower did not have slip resistant material on the bottom of the shower or bathtub.
Corrective Action(s): Ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower.
Date to be Corrected: November 03, 2018

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of the freezer found that many items were not labelled and dated.
Corrective Action(s): Ensure that all food is labelled and dated to ensure food safety.
Date to be Corrected: November 3, 2018

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Review of the menu identified that two snack times are listed but no listing of what is available for snacks.
Corrective Action(s): Ensure that snacks provided contain at least 2 food groups as described in Canada's Food Guide.
Date to be Corrected: November, 3, 2018

NUTRITION AND FOOD SERVICES: 37070 - RCR s.62(2)(c)(iii) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (iii) seasonal variations in food.
Observation: A review of the menu determined that breakfast offered was the same each day.
Corrective Action(s): Ensure that the menu provides a variety of foods, taking into consideration seasonal variations in food.
Date to be Corrected: November 3, 3018

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of the menu documentation found no menu audits for the current menu.
Corrective Action(s): Ensure that nutrition documentation is complete.
Date to be Corrected: November 3, 2018


Comments

This LO would like to thank the Manger 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/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.