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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME Am'ut		SERVICE TYPES 201 Child & Youth Residential	FACILITY LICENSE # LBJE-6HXRCG
FACILITY ADDRESS Removed at operator's request			FACILITY PHONE Removed at operator's request
CITY Chilliwack	POSTAL CODE Removed at operator's request		MANAGER Removed at operator's request

INSPECTION DATE July 25, 2017	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 5
ARRIVAL 10:45 AM	DEPARTURE 03:45 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

A scheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s(LO) observations, review of facility records and information provided by facility staff at the time of the inspection. The program's Clinical Director was also present for this inspection. As part of the Routine Inspection a 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. A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights. Visit CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to legislation (CCALA and RCR)

Contraventions

Previous Inspection - Not Applicable

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: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface. Observation: The laundry area used by persons in care has tile flooring which did not have a slip resistant surface. Corrective Action(s): Please ensure flooring in the laundry area is safe for persons in care. Date to be Corrected: July 28, 2017

Comments

Staffing Licensing scheduled this inspection as approximately 6 months ago a new Manager was appointed and this was her first time being present for a Licensing inspection. This allowed Licensing to take extra time to explain the inspection process and answer her questions. The Manager explained their program and various self-monitoring tools she used to ensure compliance to legislation is maintained including inspection checklists. Other staff present also appeared to have a clear understanding of their program as they were able to answer Licensing questions and demonstrate various systems inspected. Care & Supervision During this inspection there were no youth in care as the Manager is in the process of admitting new youth and their previous youth had graduated from the program on July 21, 2017. The Manager explained their admission process and documentation gathered during the process. Licensing reviewed the youth's file who had recently graduated and all required information was on file meeting care planning requirements. This report was written off-site and is included in the time spent. Licensing met with the Manager off-site on July 27, 2017 to review and discuss this report and the risk assessment tool. Licensing requests a written response be submitted on or before August 11, 2017 describing how the above noted contravention has been appropriately addressed. If you have any questions regarding this inspection report, please contact your Licensing Officer.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Aug 11, 2017

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