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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME 216A Street		SERVICE TYPES 140 Community Living	FACILITY LICENSE # TGAL-95RQ8D
FACILITY ADDRESS 8983 216A St			FACILITY PHONE (604) 293-0284
CITY Langley	POSTAL CODE V1M 4C7		MANAGER Corey Nonis

INSPECTION DATE January 28, 2022	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.25
ARRIVAL 11:00 AM	DEPARTURE 01:20 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

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 -

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

Observed Violations

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned. Observation: All but one staff person has had their yearly performance evaluation which leadership is aware. The Policy is for staff to have yearly performance evaluations. Corrective Action(s): Please ensure regular performance review is conducted. Date to be Corrected: March 7, 2022

Comments

The information was also gathered through correspondence with leadership. Licensing would like to thank the staff for their assistance during the inspection.The inspection report was written off site due to the Infection Prevention Measures related to pandemic. A copy of the inspection report, along with the Risk Assessment was sent via email Please provide a written response to how the coded violations will be addressed by February 15, 2022. If you have any questions or concerns regarding this report, please contact me

Action Required by Licensee/Manager	Action Required by Licensing Staff
Provide a written response to Licensing	No action required
Due Date Feb 15, 2022

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