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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JFUR-CVZTQP

FACILITY NAME
Thornton
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
TDAH-82LV3P
FACILITY ADDRESS
11960 249A St
FACILITY PHONE
(604) 463-5188
CITY
Maple Ridge
POSTAL CODE
V4R 2E3
MANAGER
Robert Hicks

INSPECTION DATE
September 25, 2023
ADDITIONAL INSP. DATE (multi-day)
September 25, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
12:00 PM
DEPARTURE
01:15 PM
ARRIVAL
02:30 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

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 as part of a routine inspection:
- Licensing
- Physical Facility
- 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.

Visit the CCFL website at https://www.fraserhealth.ca/residentialcare for:
-Additional resources and
-Links to the Legislation (CCALA & RCR)

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 (CORRECTED DURING INSPECTION): Upstairs PIC bathroom water temperature measured at 51.6 degrees celsius.
Corrective Action(s): A licensee must endure that water accessible to a person in care, from any source, is not heated to more 49 degree celsius.
Date to be Corrected:

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Employee performance reviews were not updated annually.
Corrective Action(s): A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Date to be Corrected: 9-October-2023


Comments

Thank you for your time and assistance with completing this inspection.

Please submit a written response by October 9, 2023 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

(Please note: this inspection report was reviewed with the Manager, written on-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
Oct 09, 2023

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