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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-BJLPG8

FACILITY NAME
Five Corners Residence
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982373
FACILITY ADDRESS
21451 Old Yale Rd
FACILITY PHONE
(604) 533-9332
CITY
Langley
POSTAL CODE
V3A 4M6
MANAGER
Regina Awotwi-Pratt

INSPECTION DATE
December 06, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
09:15 AM
DEPARTURE
12:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled 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 #NTJN-B9USX5 have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Review of the care plan captured in the MAR for 1 of 4 persons in care (PIC) determined that it was last updated on June 19, 2018.
Corrective Action(s): Ensure that all care plans are reviewed once each year.
Date to be Corrected: January 6, 2020

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation (CORRECTED DURING INSPECTION): Review of 1 of 4 persons in care was missing the November monthly weight. Discussion with staff confirmed that a weight was not obtained as the scale was broken. It was discussed that if a weight cannot be obtained then staff should record the reason why the weight could not be obtained.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: January 6, 2020


Comments

This LO would like to thank the Staff 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
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Jan 06, 2020

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