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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-BURMLQ
FACILITY NAME
Delta Lodge		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
MLAO-8ZCLTU
FACILITY ADDRESS
11030 River Rd		FACILITY PHONE
(604) 951-9415
CITY
Delta		POSTAL CODE
V4C 2S2		MANAGER
Sue (Sukhwinder) Hundal
INSPECTION DATE
October 20, 2020		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
12:30 PM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

Routine Inspection Report

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:

- 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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2CWtTpKipp for:

- Additional resources, and
- Links to the legislation (CCALA and 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: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: In the laundry room 2 large containers of bleach were observed. The chemicals were not located in a locked or secure cupboard. It appeared that this cupboard did previously have a lock on the door however this lock was no longer functional.
Corrective Action(s): Please ensure that all chemicals are safely and securely stored.
Date to be Corrected: October 30, 2020

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: It was noted that residents do have access to the laundry room. There was no slip resistant surfacing or mat located in front of the washing machines.
Corrective Action(s): Please ensure a slip resistant surface or mat is placed in front of the laundry machines to ensure resident safety.
Date to be Corrected: October 30. 2020
Comments

The following resource was provided to the Licensee:
- Updated/revised 'Guideline for TB Control'.

This Licensing Officer would like to thank the manager and staff for their assistance in completing this routine inspection.

This report was forwarded to the Manager.

Please contact your Licensing Officer if you have any questions or concerns.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Due Date
Oct 30, 2020		Approximate Follow Up Date
13 Nov, 2020
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Click here for a description of each "Category" of violation displayed.