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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CV6P7F
FACILITY NAME
Delta Lodge		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
MLAO-8ZCLTU
FACILITY ADDRESS
11030 River Rd		FACILITY PHONE
(604) 951-9415
CITY
Delta		POSTAL CODE
V4C 2S2		MANAGER
Sue (Sukhwinder) Hundal
INSPECTION DATE
August 22, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
12:30 PM		DEPARTURE
02:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

ROUTINE INSPECTION

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.

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.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
RECORDS AND REPORTING: 39410 - RCR s.86(a) - A licensee must keep the following records in respect of each employee: (a) criminal record check results,.
Observation: In review of staff files, 3 staff were noted to have expired criminal record checks (CRC) and 1 staff did not have a CRC on file.
Corrective Action(s): Please ensure all staff have current criminal record checks on file.
Date to be Corrected: September 29, 2023
Comments

This LO would like to thank the manager and staff for their assistance in completing this routine inspection.

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
Sep 08, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.