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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

SCLY-AGSSSQ

FACILITY NAME Fletcher 2		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081366
FACILITY ADDRESS 12076 Fletcher St			FACILITY PHONE ()
CITY	POSTAL CODE		MANAGER Cindy Feuer

INSPECTION DATE December 19, 2016	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 1.25
ARRIVAL 12:30 PM	DEPARTURE 01:45 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Follow-up					# CHILDREN ENROLLED

Introduction

An unscheduled follow-up inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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: · Nutrition and Food Services Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for: Additional resources, and Links to the Legislation (CCALA and RCR)

Contraventions

Previous Inspection - Contraventions observed on FIR #SCLY-AE2REL have been corrected except for those noted on supplementary pages.

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

Observed Violations

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value. Observation: A substitution record was reviewed and found that some of the substitutions are not from the same food group and do not have a similar nutritional value. Discussion with the manager determined that this was the person in cares choice. Although they are not the same food group or same nutrition value, processed food and unhealthy choices were no longer being substituted as much as observed in the previous inspection. Corrective Action(s): Please ensure that substituted items are made from the same food group and have similar nutritional value. Date to be Corrected: January 13, 2016 NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan. Observation: A new menu has been created and an audit has been filled out for one of the weeks, but some of the food groups are not calculated properly. The manager and licensing went over the audit and how to fill it out. Corrective Action(s): Please ensure that each person in case receives adequate food to meet there personal nutrition needs based on Canada's Food Guide and their nutrition care plan. Date to be Corrected: January 13, 2016

Comments

Licensing would like to thank the staff for all the work they have done with nutrition at this facility and the progress that has been made.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance	No action required

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