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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CYFS2W

FACILITY NAME
Chelsey House 2003 Ltd
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
MLAO-7J4U55
FACILITY ADDRESS
4544 216th St
FACILITY PHONE
(604) 530-0352
CITY
Langley
POSTAL CODE
V3A 2M4
MANAGER
Harpreet Cumo

INSPECTION DATE
December 12, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.75
ARRIVAL
01:15 PM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
10

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
- 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.

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: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation (CORRECTED DURING INSPECTION): During physical inspection it was noted that the fire extinguishers were due for annual service before Nov 18, 2023 and are now overdue. Each extinguisher guage was green which indicates good pressure and they will work.
Corrective Action(s): Ensure that all equipment and monitoring and signalling devices are inspected and maintained on a regular basis.
Date to be Corrected:


Comments

This Licensing Officer would like to thank the Manager and Staff for assistance completing this routine inspection.

No further response is required as the contravention that was identified during inspection was corrected immediately.

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

Please note: this inspection report was reviewed with the manager on site and signed. It was then sent to the Manager via email.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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