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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-BLYR97

FACILITY NAME
Jackman Manor
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0982301
FACILITY ADDRESS
27477 28th Ave
FACILITY PHONE
(604) 856-4161
CITY
Aldergrove
POSTAL CODE
V4W 3L9
MANAGER
Denise Morin

INSPECTION DATE
February 18, 2020
ADDITIONAL INSP. DATE (multi-day)
February 19, 2020
ADDITIONAL INSP. DATE (multi-day)
February 20, 2020
TIME SPENT (HRS.)
113
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
10:15 AM
DEPARTURE
02:30 PM
ARRIVAL
11:00 AM
DEPARTURE
02:00 PM
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)
If you have any questions regarding this report, please feel free to contact the geographic area Licensing Officer.

Contraventions
Previous Inspection - Contraventions observed on FIR #KDHL-BD5SFF have been corrected.
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: 31330 - RCR s.23(a) - A licensee must ensure that (a) no one other than a person in care smokes or uses tobacco, holds lighted tobacco, uses an e-cigarette or holds an activated e-cigarette while on the premises of a community care facility,
Observation: During the first day of inspection, it was observed that staff were smoking at the corner of the parking lot which is still identifed as the facility premises.
Corrective Action(s): Ensure that smoking by staff is not on the premises of the facility
Date to be Corrected: March 20, 2020

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of the weight documentation for February found that two weights were documented for March 2020. Discussion with staff determined that the staff did not know that the weight was previously obtained.
Review of 5 care plans found that one care plan did not have a weight documented for October 2019 and there was no documentation as to why the weight was not obtained and the computer captured it as March.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: March 20, 2020


Comments

This LO would like to thank the Manager, Director of Care, and staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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
Mar 20, 2020

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