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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-C4XN28

FACILITY NAME
Ladner 2
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982991
FACILITY ADDRESS
5010 Westminster Ave
FACILITY PHONE
(604) 940-1061
CITY
Delta
POSTAL CODE
V4K 2H9
MANAGER
Shukri Kullane

INSPECTION DATE
July 14, 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
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: During inspection of the outdoor patio, the following was noted:
- A large hole was observed in the concrete surface in close proximity to the covered gazebo. The hole was noted to have 3 wires of unknown origin. The manager stated that maintenance staff have confirmed that these wires are not electrical. This hole was noted to be large enough to be a tripping hazard.
Corrective Action(s): Please ensure all common areas are maintained in a good state of repair. Although a 2 week correction date has been noted to repair the concrete, temporary solutions to ensure safety were discussed with the manager such as a cover for the hole or placement of a planter.
Date to be Corrected: July 29, 2021.

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: Review of the emergency policy noted the following:
- Items identified on the 3 day emergency food supply list were no longer being used or in stock. Additionally, the policy included a former resident and their diet needs and not the new admission.

Corrective Action(s): Please ensure the emergency plan is revised to reflect the current residents in the home and the current provision of food supplies.
Date to be Corrected: July 29, 2021


Comments

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

Please provide a written response by July 29, 2021 regarding how the noted contraventions will be addressed.

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
Jul 29, 2021

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