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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CNDNTU
FACILITY NAME
Irene Thomas Hospice		SERVICE TYPES
110 Hospice
FACILITY LICENSE #
MLAO-BZEV66
FACILITY ADDRESS
4635 Clarence Taylor Cres		FACILITY PHONE
(604) 946-1121
CITY
Delta		POSTAL CODE
V4K 4L8		MANAGER
Jo-Anne Kirk

INSPECTION DATE
January 18, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
09:30 AM		DEPARTURE
01:30 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.
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: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Cleaning agents were observed to be stored in the family use laundry room. This laundry room is accessible to persons in care.
Corrective Action(s): Please ensure all cleaning agents and chemical products are stored in a secure manner at all times.
Date to be Corrected: January 27, 2023

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31790 - RCR s.35(2)(b) - A licensee must ensure that laundry facilities (b) if not used by persons in care, cannot be accessed by persons in care.
Observation: The door to the main laundry facility room that is not used by persons in care was not secured at the time of this inspection. Cleaning agents were noted to be stored in the room.
Corrective Action(s): Please ensure the laundry facility room that is not for use by persons in care is secured at all times.
Date to be Corrected: january 27, 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 February 3, 2023 as to how the identified contravention in this report will be addressed.

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

(Please note: this inspection report was written off-site and forwarded to the Licensee)
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
Feb 03, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.