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

FACILITY NAME
Christel House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0904186
FACILITY ADDRESS
11753 82nd Ave
FACILITY PHONE
(604) 597-1286
CITY
Delta
POSTAL CODE
V4C 2C3
MANAGER
Firoza (Neelu) Sahim

INSPECTION DATE
February 22, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:00 AM
DEPARTURE
03:00 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.

Visit the Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2CWtTpKipp for:

- Additional resources, and
- Links to the legislation (CCALA and RCR).

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

Observed Violations
LICENSING: 30250 - CCALA s.7(1)(c.1)(i) - A licensee must do all of the following: (c.1) display the rights of adult persons in care (i) in a prominent place in the community care facility.
Observation: The Residents Bill of Rights was displayed in the manager's office, located behind a monitor. It was communicated that the bill of rights must be displayed in a prominent location to ensure awareness for persons in care and their representatives or family members.
Corrective Action(s): Please ensure the bill of rights is posted in a prominent location accessible to persons in care and families.
Date to be Corrected: March 8, 2021

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 the inspection of the physical facility the following was noted:
- A hole was noted in the wall behind a chair of 1 person in care's bedroom on the lower floor,
- The latch on the gate leading off the back patio was bent causing the latch to no longer secure the gate,
- The front door side window was noted to be cracked. The manager is aware of this and is in process of being repaired,
- The drawer in the refrigerator was noted to be cracked and missing a front piece. The front edges of this drawer were noted to be sharp and could pose a risk to persons in care,
- The back patio surfacing was noted to be slippery due to a build up of green algae. The surface paint appears to have worn off the surface. The manager stated there is a plan to power wash and paint the wooden patio.

Corrective Action(s): Please ensure all areas are maintained in a good state of repair.
Date to be Corrected: March 22, 2021.

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: In the lower bathroom the stand up shower appeared to not have a slip resistant material on the shower floor. The surfacing appeared very smooth, and would pose a fall risk.
Corrective Action(s): Please ensure all bathrooms have a slip resistant material on the bottom.
Date to be Corrected: March 8, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: During inspection of the laundry room, a mat was observed on the floor in front of the dryer machine. However, no slip resistant material was noted in front of the washing machine. The mat that was being used in the laundry room was noted to move easily on the floor which could be a risk for falls.
Corrective Action(s): Please ensure a slip resistant floor is in the laundry room.
Date to be Corrected: March 8, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): It was noted in the downstairs bathroom that 2 tubes of medicated cream prescribed by the physician were stored on the open shelf.
Corrective Action(s): Please ensure all medications are securely stored, including any medicated creams.
Date to be Corrected: This was corrected immediately by the Manager.


Comments

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

This report was reviewed and discussed with the DOC. Please provide a written response to how the noted contraventions will be addressed by March 5, 2021.

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

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
Mar 05, 2021

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