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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

WCLK-ASVQZP

FACILITY NAME Christel House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0904186
FACILITY ADDRESS 11753 82nd Ave			FACILITY PHONE (604) 597-1286
CITY Delta	POSTAL CODE V4C 2C3		MANAGER Patti Kimball

INSPECTION DATE November 07, 2017	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3
ARRIVAL 09:10 AM	DEPARTURE 12:10 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

A scheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s (LO) observations, review of facility records and information provided by facility staff at the time of the inspection. As part of the Routine Inspection a 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. A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights. Visit CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to legislation (CCALA and RCR)

Contraventions

Previous Inspection - Contraventions observed on FIR #WCLK-AF3Q5L have been corrected.

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

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 4 week menu plans there were days where only 1 food group was offered (ie jello and fruit). In discussion with staff they stated they often include a choice of fruit in addition to what is documented. Corrective Action(s): Please ensure choices offered are documented on the menu and that the snacks on the menu incudes 2 food groups. Date to be Corrected: December 15, 2017

Comments

Physical Facility The flooring in the kitchen and entry landing have been replaced. To address wooden flooring in the living room a large area rug has been placed over the floor. Copies of the inspection report and the Risk Assessment Tool were reviewed, discussed, and provided to the Manager. Please contact your Licensing Officer if you have any questions or concerns regarding this report.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance	No action required
Due Date Nov 07, 2017

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