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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CQCPMG
FACILITY NAME
Delta View Habilitation Centre		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LSEO-ATUREH
FACILITY ADDRESS
9341 - Burns Dr		FACILITY PHONE
(604) 501-6713
CITY
Delta		POSTAL CODE
V4K 3N3		MANAGER
Tracy Nikkel
INSPECTION DATE
March 24, 2023		ADDITIONAL INSP. DATE (multi-day)
March 28, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
01:00 PM		DEPARTURE
04:00 PM		ARRIVAL
10:30 AM		DEPARTURE
12:30 PM		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
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: In review of the Policy and Procedure Manual, specifically the Policy on 'Emergency Planning' it was noted that the policy was last reviewed and revised in 2019. Information that is outdated was noted in the policy.
Corrective Action(s): Please ensure that Policies are reviewed at least once each year.
Date to be Corrected: April 21, 2023

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: In review of the Policy Manual for Emergency Planning, it was noted that fire drills must occur every month. Currently, fire drills are not occurring as directed by policy.
Corrective Action(s): Please ensure policies are implemented by employees.
Date to be Corrected: April 21, 2023
Comments

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

Please provide a response to Licensing by April 21, 2023 as to how the identified contraventions in this report will be addressed.

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
Apr 21, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.