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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-D9VSBG

FACILITY NAME
Augustine House
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
MLAO-5UJNWS
FACILITY ADDRESS
3820 Arthur Dr
FACILITY PHONE
(604) 940-6005
CITY
Delta
POSTAL CODE
V4K 5E6
MANAGER
Naaz Khan

INSPECTION DATE
October 04, 2024
ADDITIONAL INSP. DATE (multi-day)
October 09, 2024
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
10:30 AM
DEPARTURE
01:00 PM
ARRIVAL
10:30 AM
DEPARTURE
03:00 PM
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)

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

Observed Violations
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Two staff are missing their CRC
Corrective Action(s): Please ensure CRC is complete and on file.
Date to be Corrected: October 22, 2024

STAFFING: 32083 - RCR s.37(3)(c) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Two staff are missing their TB,Immunization status
Corrective Action(s): Please ensure staff files are complete
Date to be Corrected: October 31, 2024

STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Several staff are missing their performance reviews which are required every 2 years.
Corrective Action(s): Please ensure performance reviews are conducted as per the Policy.
Date to be Corrected: December 31, 2024


Comments

Discussion regarding record keeping of weights ensure the different systems provides the relevant information.
Leadership is aware of missing staff files and in the process of ensuring all requirements are met.
Licensing would like to thank the staff for all of the time provided during the inspections.
Please provide an action plan to address the contraventions by October 18, 2024
Copy of the report will be forwarded.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Oct 18, 2024

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