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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CTANQA

FACILITY NAME
Fernridge Place
SERVICE TYPES
150 Acquired Injury
FACILITY LICENSE #
KSTZ-6QKQWD
FACILITY ADDRESS
2107 200th St
FACILITY PHONE
(604) 533-2235
CITY
Langley
POSTAL CODE
V2Z 1Z6
MANAGER
Dana McKague

INSPECTION DATE
June 30, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.25
ARRIVAL
11:30 AM
DEPARTURE
01:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
13

Introduction

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 as part of a routine inspection:
- 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 CCFL website at https://www.fraserhealth.ca/residentialcare for:
-Additional resources and
-Links to the Legislation (CCALA & 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
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation (CORRECTED DURING INSPECTION): Review of the 4 week menu found that 2 daily snacks are listed, but in more than 5 snacks each week only shows 1 food group.
Corrective Action(s): Please ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Date to be Corrected:

RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection 77(3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: LO noted in preparation for the Routine Inspection that there were no reportable incidents submitted by the team at Fernridge since the Routine in July of 2022. Review of Internal Incidents/FH ABI Incident Reporting forms from August 2022 through to June 2023 the site completed 21 internal incident or ABI reportable incidents and 4 of 21 met the definition of reportable to Licensing, per schedule D.
Corrective Action(s): Ensure that if a person in care is involved in a reportable incident the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer.
Date to be Corrected: July 14, 2023


Comments

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

Please provide a written response by July 14 , 2023 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

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

(Please note: this inspection report was reviewed with the staff on site and signed It was then sent with the corresponding risk assessment to the Manager/ Licensee via email.)

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 14, 2023

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