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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-AQZN2X
FACILITY NAME
Fletcher 2		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081366
FACILITY ADDRESS
12076 Fletcher St		FACILITY PHONE
(604) 463-7444
CITY
Maple Ridge		POSTAL CODE
V2X 6K9		MANAGER
Angaline Madhavan
INSPECTION DATE
September 07, 2017		ADDITIONAL INSP. DATE (multi-day)
September 08, 2017		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
03:45 PM		DEPARTURE
05:00 PM		ARRIVAL
09:00 AM		DEPARTURE
10:30 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)
If you have any questions regarding this report feel free to contact me at 604-949-7714 or by email at nicholas.birch@fraserhealth.ca

Contraventions
Previous Inspection - Contraventions observed on FIR #SCLY-AE2REL have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
CARE AND/OR SUPERVISION: 34110 - RCR s.50(2)(b) - A licensee must not (b) transfer a person in care, other than a person in care who is on leave under the Mental Health Act, to another community care facility without the consent of the person in care or that person's parent or representative.
Observation: A review of 2 PIC's care plans found no consent for hospital transfer in either file.
Corrective Action(s): Please ensure all PIC's have consent for hospital transfer on file.
Date to be Corrected: September 30 2017
Comments
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.