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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-D2B2SJ
FACILITY NAME
Peace Arch Hospital ECU		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962LQ8
FACILITY ADDRESS
15521 Russell Ave		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Imaan Toor / Gurpreet Gill
INSPECTION DATE
February 09, 2024		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:30 AM		DEPARTURE
01:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

This is a follow-up inspection to the routine inspection report # CRAU-CWZUQP completed with the Managers for Dr. Al Hogg Pavilion and Weatherby 2.
Contraventions
Previous Inspection -
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The hot water temperature was randomly checked in Dr. Al Hogg Pavilion. One reading was at 55.1 degrees Celsius and slowly increasing. The Manager for Dr. Al Hogg Pavilion stated as part of the written response to the routine inspection report and during the follow-up inspection on February 9, 2024 that this matter was looked into and addressed and long term solutions are being looked at.
Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: February 12, 2024.
Comments

It appears at this time all items noted in the routine inspection report have been completed and systems are in-place such as on-going auditing of documentation to ensure documentation is thoroughly completed. There is one outstanding item that needs to be addressed as per section 17 of the Residential Care Regulation regarding the hot water temperature (Please refer to the section of this report on this).

If there are any questions related to this inspection report, please contact your Licensing Officer.
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
Feb 12, 2024
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