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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-C3LSTS

FACILITY NAME
Cabeldu
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0901267
FACILITY ADDRESS
6473 Cabeldu Cres
FACILITY PHONE
(604) 590-4988
CITY
Delta
POSTAL CODE
V4E 1R2
MANAGER
Manpreet Randhawa

INSPECTION DATE
June 02, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
10:30 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
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
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of 4 week menu shows that there were two times when the dinner served included only vegetable and meat.
Corrective Action(s): Please ensure each meal contains at least 3 food groups from the Canada Food Guide
Date to be Corrected: July 13, 2021

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: One out of the two daily required snacks did not contain 2 food groups for snacks.
Corrective Action(s): Please ensure snacks contain at least 2 food groups from the Canada Food Guide
Date to be Corrected: July 13, 2021

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the substitution list shows that vegetable samosa was substituted for hamburger.
Corrective Action(s): Please ensure substitutions occur from the same food group.
Date to be Corrected: ongoing


Comments

Updates of staff information was provided
All Policies and Procedures, Care plans have had their yearly review.
Due to the COVID pandemic the report was written offsite but was discussed at the time of the inspection with the Manager.
Please provide a written response to how the coded violations will be addressed by June 29, 2021.
Thank you to all the staff for their assistance during the inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jun 29, 2021

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