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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-ABMVGN

FACILITY NAME
Raven House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
PWIN-6SVT38
FACILITY ADDRESS
841 Levis St
FACILITY PHONE
(604) 931-1547
CITY
Coquitlam
POSTAL CODE
V3J 6A2
MANAGER
Bryan Davis

INSPECTION DATE
July 07, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
02:15 PM
DEPARTURE
05:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
3

Introduction

This is an unscheduled Routine Inspection to assess compliance with the community Care and Assisted Living Act (CCALA) and the pursuant Residential Care Regulations (RCR). The Licensing Officer's Reference Guide to Residential Care Database Coding was used to assist in providing consistency. the following systems were reviewed:
1. Licensing
2. Physical Facility
3. Staffing
4. Policies and Procedures
5. Care and Supervision
6. Hygiene and Communicable Disease Control
7. Medication
8. Nutrition and Food Services
9. Program
10. Records and Reporting

Resources provided:

The Licensing Officer's Reference Guide to Residential care Database Coding
Abbreviated Checklist of Required Records
Canada's Food Guide
Caring About Food Safety at: www.foodsafety.gov.bc.ca

Contact information:
valerie.dairon@fraserhealth.ca
604-949-7710.

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-9ZDUVC 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
LICENSING: 30150 - RCR s.11(1)(a) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (a) both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation: The license could not be located. Staff will search and notify licensing for replacement if necessary.
Corrective Action(s): Please insure that license is displayed in appropriate manner.
Date to be Corrected: July 21, 2016

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Meals observed with only 2 food groups
Corrective Action(s): Please ensure that all meals have 3 food groups
Date to be Corrected: July 21, 2016

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: All snacks observed had only one food group.
Corrective Action(s): Please ensure that all snack contain 2 food groups.
Date to be Corrected: July 21, 2016

RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: The MAR was observed to have a PRN with no results documented and a day of missing medications with no reason documented.
Corrective Action(s): Please provide a plan that will ensure that all medications are appropriately documented every time.
Date to be Corrected: July 21, 2016

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: Weights observed to be missing for one PIC since February.
Corrective Action(s): Please provide a plan that will ensure that weights are taken every month or the reason is documented if the weight is not done.
Date to be Corrected: July 21, 2016


Comments

The front entrance has recently had a face lift with new paint, new flooring and new non-slip coverings for stair tread.
The manager states he is away for the week of July 18-22, 2016 to response time for this inspection has been moved to August 3, 2016.
I would like to thank the staff for their assistance with this inspection. The facility residents were observed to interact in a quiet and respectful manner to each other. There is a much greater sense of relaxed calm to the house than observed on previous visits.

Due totechnical difficulties this document was not signed by LO.

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 03, 2016

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