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

EJON-CQCR7Z

FACILITY NAME Delta View Life Enrichment Centre		SERVICE TYPES 401 Long Term Care (Hospital Act)	FACILITY LICENSE # LBAA-95YTAC
FACILITY ADDRESS 9321 Burns Dr			FACILITY PHONE (604) 501-6700
CITY Delta	POSTAL CODE V4K 3N3		MANAGER Tracy Nikkel

INSPECTION DATE March 24, 2023	ADDITIONAL INSP. DATE (multi-day) March 28, 2023		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 7
ARRIVAL 10:00 AM	DEPARTURE 03:00 PM	ARRIVAL 12:30 PM	DEPARTURE 02:30 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

Routine Inspection Report An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 - Policies and Procedures - Care and Supervision - Hygiene and Communicable Disease Control - Medication - Nutrition and Food Services - Program - Records and Reporting As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Contraventions

Previous Inspection -

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

Observed Violations

POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year. Observation: In review of the Emergency Plan policy, the previous review date was in 2019. Changes have occurred at the facility, and it was evident that these changes were not noted to the policy. Corrective Action(s): Please ensure that policies are reviewed and if necessary revised at least once each year. Date to be Corrected: April 21, 2023 POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: In review of the emergency fire drills, it was noted that monthly fire drills have not occurred as required by policy. Corrective Action(s): Please ensure that policies are implemented by employees. Date to be Corrected: April 21, 2023

Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection. Please provide a response to Licensing by April 21, 2023 as to how the identified contraventions in this report will be addressed. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Apr 21, 2023

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