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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CRBPR7
FACILITY NAME
Pioneer House		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
2520020
FACILITY ADDRESS
220 Sherbrooke St		FACILITY PHONE
(604) 521-1205
CITY
New Westminster		POSTAL CODE
V3L 3M2		MANAGER
Jeannine Corrigan/ Rudy Young
INSPECTION DATE
April 28, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
12:30 PM		DEPARTURE
03:05 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). 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 & 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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing

Residential Care Regulation
Community Care and Assisted Living Act
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: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: The Licensee’s policy and procedure required that staff’s performance review are completed every 2 years . Three of 5 staff have no completed performance review on file.
Corrective Action(s): Staff performance review must be completed according to the licensee's policies and procedures.
Date to be Corrected: May 12, 2023

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: PRN medication effectiveness were not recorded to 2 persons in care.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 12, 2023
Comments

Facility has building maintenance system in place. Active monitoring on medications and food storage are implemented.

Thank you to all the staff for their assistance and cooperation with the completion of this focused routine inspection.
The findings were discussed with the facility leadership and the report was written and signed at the site.
The copy of the report and risk assessment were provided via email.

Please submit a written response to this routine inspection to Licensing by May 12, 2023.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
May 12, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.