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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

NTJN-BD4SJ3

FACILITY NAME Graceland Gates		SERVICE TYPES 140 Community Living 150 Acquired Injury	FACILITY LICENSE # NNAL-8N3MVT
FACILITY ADDRESS 6587 238th St			FACILITY PHONE (604) 510-4283
CITY Langley	POSTAL CODE V2Y 2H5		MANAGER Deidra Vanderlee

INSPECTION DATE June 13, 2019	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.5
ARRIVAL 11:24 AM	DEPARTURE 02:43 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) If you have any questions regarding this report, please feel free to the area Licensing Officer.

Contraventions

Previous Inspection - Contraventions observed on FIR #NTJN-AXJR4K have been corrected.

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

Observed Violations

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month. Observation (CORRECTED DURING INSPECTION): Review of 1 of 4 PIC care plans found one missing weight for one month. It was determined that the PIC was not at the facility and that is why the weight was not obtained. Corrective Action(s): Ensure that each person in care is weighed at least once each month or a reason why the PIC cannot be weighed is recorded. Date to be Corrected: CORRECTED DURING INSPECTION

Comments

his LO would like to thank the Manager and Staff for their time and assistance in completing this inspection. This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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