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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-C2NSNJ

FACILITY NAME
English Bluff
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0920120
FACILITY ADDRESS
4836 13th Ave
FACILITY PHONE
(604) 943-5173
CITY
Delta
POSTAL CODE
V4M 2B8
MANAGER
Stacey Gentry

INSPECTION DATE
April 30, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.75
ARRIVAL
10:00 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)

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: Both of the bathroom faucets had temperature reading of 58C.
Corrective Action(s): Please ensure the water accessible to a person in care does not exceed 49C
Date to be Corrected: June 18, 2021

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: The door frame area for bathroom and bedroom, along with one of the PIC door has areas of wear and tear.
Corrective Action(s): Please ensure the rooms are in a good state of repair
Date to be Corrected: June 30, 2021

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Menu included dinner options at least twice in a week where it did not meet the requirement of having at least 3 food groups described in the Canada Food Guide
Corrective Action(s): Please ensure that meals include at least 3 food groups from the Canada Food Guide
Date to be Corrected: June 15, 2021

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: The snack menu does not ensure that it meet the requirement of having at least 2 food groups
Corrective Action(s): Please ensure that minimum 2 nutritious snacks include with 2 food groups per snack
Date to be Corrected: June15, 2021

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): From the month of March to October 2020, monthly weights were not conducted due to lack of access of the scale.
Corrective Action(s): Each person needs to be weighed at least once month. Licensing discussed that Licensee could have applied for an exemption at the time when the requirement could not been met.
Date to be Corrected: as required


Comments

Please provide a written response to how the above coded violations will be addressed by May 19, 2021.
Due to the COVID Pandemic, the report was written offsite, but details discussed with the Manager at the time of the inspection.
Please also ensure the Licensee contact is made aware of this 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.