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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CHKUCA
FACILITY NAME
58th Avenue Home		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782286
FACILITY ADDRESS
29172 58th Ave		FACILITY PHONE
(604) 856-3278
CITY
Abbotsford		POSTAL CODE
V4X 2G1		MANAGER
Keri Thomson
INSPECTION DATE
August 22, 2022		ADDITIONAL INSP. DATE (multi-day)
September 07, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:00 AM		DEPARTURE
12:30 PM		ARRIVAL
12:30 PM		DEPARTURE
03:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: A toilet brush was noted to be stored in the cupboard in close proximity to the PIC's clean supplies.
Corrective Action(s): Please ensure these items are kept separate to avoid cross contamination.
Date to be Corrected: Sept 9, 2022

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: Review of PRN medication administration records found, signatures of medications administered to PIC's missing from the MAR on at least 3 occasions over 3 months reviewed.
Corrective Action(s): Ensure all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Sept 16, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation (CORRECTED DURING INSPECTION): For one person in care, there was no evidence of immunization or TB screening prior to admission to the care facility.
Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Province's immunization and TB control programs.
Date to be Corrected: This was corrected before the 2nd day of the inspection.
Comments

Discussed during inspection, The out building that is being used to store items for other homes, and donated supplies.

It is requested that a written response be submitted on or before September 16th describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

(Please note: due to infection control practices related to COVID-19 prevention, this inspection report was reviewed with the Manager, written off-site and forwarded to the Licensee. Therefore no signature was obtained.)
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Sep 16, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.