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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-ATEQ6U
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
Mary Jean Banman
INSPECTION DATE
November 23, 2017		ADDITIONAL INSP. DATE (multi-day)
November 24, 2017		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
10:30 AM		DEPARTURE
12:30 PM		ARRIVAL
09:30 AM		DEPARTURE
11:30 AM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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 - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
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: It was observed that one person in care's food intake record was completed prior to snack and lunch on day one of the licensing inspection. In discussion with the manager, the food intake record is to be completed after the person in care has had the meal to ensure accurate documentation of time and intake amounts.
Corrective Action(s): Ensure staff are implementing policies and procedures.
Date to be Corrected:

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of substitution records for two persons in care, on three occasions item for item was not substituted.
Corrective Action(s): Ensure that each menu provided for substitutions to be made that are from the same food group and have similar nutritional value.
Date to be Corrected: December 22, 2017
Comments

Review of policies and procedures. The society reviews policies and procedures and sends updates when they occur. Licensing has provided Residential Care Bulletin on Policies, Procedures and Plan requirements for managers review to ensure they meet the intent of RCR s.85(1)(b).
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
Dec 22, 2017
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.