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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

CRAU-CPPVE5

FACILITY NAME Peace Arch Hospital ECU		SERVICE TYPES 401 Long Term Care (Hospital Act)	FACILITY LICENSE # LBAA-962LQ8
FACILITY ADDRESS 15521 Russell Ave			FACILITY PHONE ()
CITY	POSTAL CODE		MANAGER Imaan Toor

INSPECTION DATE March 07, 2023	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2.5
ARRIVAL 09:30 AM	DEPARTURE 11:30 AM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Follow-up					# OBSERVED IN CARE

Introduction

This is a follow-up inspection completed with the Manager to the routine inspection report # CRAU - CKRV9D (completed on October 31, 2022).

Contraventions

Previous Inspection -

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

Observed Violations

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius. Observation: A random measurement of the hot water temperature at a ensuite washroom sink in a person in care's bedroom measured at 52.1 degrees Celsius and slowly increasing. Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius. Date to be Corrected: March 7, 2023.

Comments

Physical Plant: - All physical plant items that are noted on the routine inspection report have been brought forth to be completed. On the first floor doors to exit into the courtyard, a health and safety plan will submitted if required for the proposed work in the future to secure these doors other than zipties. Flooring has been repaired in elevator(s). - Hand rails have been removed on all care floors and walls painted where the handrails were removed from. Section 61 and 49 (2) of the Residential Care Regulation: - Huddles with the care staff are completed as things are noted to be addressed. The Residential Care Coordinators do monthly audits as well and bring up an issues needing to be addressed with the staff where required and resolved. If the same issues arise/are repetitive, then this becomes a performance review issue and the facility management follows up accordingly. Nutrition and Food Services: - Education as to what exactly has been provided since the routine inspection on October 31, 2022 will be forwarded to the Licensing Officer. Performance appraisals: - The Manager has a plan in-place to complete these for the staff. Thank you for your time to complete this follow-up inspection. If there are any questions related to this follow-up inspection report, please contact your Licensing Officer.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Mar 10, 2023

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