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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBOI-APKTFS

FACILITY NAME
Edmonds House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203599
FACILITY ADDRESS
7731 Wedgewood St
FACILITY PHONE
(604) 521-7857
CITY
Burnaby
POSTAL CODE
V5E 2E5
MANAGER
Leslie Fusco

INSPECTION DATE
July 24, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 - Contraventions observed on FIR # have been corrected except for those noted on supplementary pages.
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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: On inspection the LO noted that one of the PIC's had a dresser and side table with scrapes on the surface
Corrective Action(s): Ensure the furniture and equipment for use by PIC's are maintained in a good state of repair
Date to be Corrected: September 15, 2017

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: During inspection the LO noted:
- carpet in the PIC is still stained from previous inspection but new flooring was seen on site and a renovation plan was submitted to CCFL. Maintenance will be in to install it by the end of July 2017
- the second bathroom has some brown spots on the caulking by the sink, build up or staining in some of the grout by the tub, paint peeling/chipping on the edge of the wall by the tub area
- tape on the door of a PIC room as it doesn't stay shut (maintenance to fix this week)
- brown and black marks on the surface of the oven by the burners and the oven door
- the gravel/dirt that meets the concrete patio surface is lower than the patio surface which could be a tripping hazard for PIC's (it is noted that PIC's do not access outside independently)
- the surface of the siding in the back of the house appears to have a layer of black dirt
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: October 15, 2017

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Review of the staffing checklist found that only 1/8 staff at the facility had a recent performance evaluation. Supervisor turnover has made evaluations difficult
Corrective Action(s): Ensure that all staff have annual performance evaluations as per BACI policy
Date to be Corrected: December 31, 2017


Comments

The organization has a temporary site supervisor at Edmonds until September, the paperwork has been submitted for the current supervisor. Thank you to the team at Edmonds for their assistance during the inspection today.

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
Aug 07, 2017

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