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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BM7MFE

FACILITY NAME
Fair Haven Burnaby Lodge
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
3200045
FACILITY ADDRESS
7557 Sussex Ave
FACILITY PHONE
(604) 435-0525
CITY
Burnaby
POSTAL CODE
V5J 3V6
MANAGER
Lynda Ells

INSPECTION DATE
February 27, 2020
ADDITIONAL INSP. DATE (multi-day)
March 02, 2020
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7.5
ARRIVAL
09:15 AM
DEPARTURE
04:15 PM
ARRIVAL
08:30 AM
DEPARTURE
09:00 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
98

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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.
A scheduled second day of the inspection was conducted to deliver the inspection report.
The following areas were reviewed:
· Licensing
· Hygiene and Communicable Disease Control
· Physical Facility
· Medication
· Staffing
· Nutrition and Food Services
· Policies and Procedures
· Program
· Care and Supervision
· Records and Reporting

As part of this 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 :http://www.gov.bc.ca/residentialcarefacility
· Additional resources, and
· Links to the Legislation (CCALA and 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
LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: At the routine inspection the LO was informed that the Manager on CCFL record retired over 6 months ago. CCFL had not been notified of a change in manager.
Corrective Action(s): Ensure that the CCFL is notified
Date to be Corrected: 06 March 2020

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Review of the Medication Administration Record (MAR) found that none of the 08:00 medications on February 27, 2020 had not been signed as having been administered. Of concern is the review occurred at 11:00 am and the missing signatures were for all persons in care with 08:00 medications. This is a repeat contravention from 2019.
Corrective Action(s): Ensure that the medication administration policy is implemented by all employees.
Date to be Corrected: 05 Mar 2020

CARE AND/OR SUPERVISION: 34430 - RCR s.73(1)(c) - A licensee must ensure that a restraint is not used unless (c) the safety and physical and emotional dignity of the person in care is monitored throughout the use of the restraint, and assessed after the use of the restraint.
Observation: Review of a care plan, of a PIC whom uses a restraint, determined that the care plan did not indicate how the restraint is to be monitored throughout the use of the restraint.
Corrective Action(s): Ensure the safety and physical and emotional dignity of the PIC is monitored throughout the use of a restraint.
Date to be Corrected: 02 March 2020


Comments

The staff files were not inspected during this inspection as they are stored off-site. A checklist was provided to the LO which itemized the relevant documents that are contained in the individual staff files. This was accepted and meets the intent of the Residential Care Regulation. This LO will review the hard copy files at the next routine inspection.
Thank you to the staff for their time and assistance in conducting this inspection.

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 06, 2020

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