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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-C56MRH

FACILITY NAME
Primrose Centre for Community Living
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
PNEL-8A2PKD
FACILITY ADDRESS
4807 Georgia St
FACILITY PHONE
(604) 946-0401
CITY
Delta
POSTAL CODE
V4K 2T1
MANAGER
Angela Keulen

INSPECTION DATE
July 21, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
10:30 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
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
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: In review of the staff files, it was noted for 2 staff that performance evaluations are overdue.
Corrective Action(s): Please ensure the performance of each employee is reviewed regularly and as directed by facility policy.
Date to be Corrected: August 18, 2021


Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection. This inspection report was discussed with the Manager.

Please provide a written response to Licensing as to how the noted contravention will be addressed by August 4, 2021.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was written off-site and forwarded to the Licensee. Therefore no signature was obtained.)

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
Aug 04, 2021

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