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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-B7KRE7

FACILITY NAME
Sakura House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081380
FACILITY ADDRESS
566 Schoolhouse St
FACILITY PHONE
(604) 939-4342
CITY
Coquitlam
POSTAL CODE
V3J 5P3
MANAGER
Bree MacColl

INSPECTION DATE
December 05, 2018
ADDITIONAL INSP. DATE (multi-day)
December 18, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
10:00 AM
DEPARTURE
12:15 PM
ARRIVAL
10:30 AM
DEPARTURE
12:30 PM
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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: The stove liners under the elements have rust holes
Corrective Action(s): Please replace the element liners
Date to be Corrected: December 28, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: During inspection it was noted that the ceiling vent in the hallway had a layer dust and dirt on it most likely due to recent construction at the facility

Corrective Action(s): Ensure all rooms and common areas are maintained in a clean condition
Date to be Corrected: December 28,2018

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: It was noted during review of the medication binder that there were 2 missing signatures for medication administration
Corrective Action(s): Ensure that medications are signed off as per the medication policy and procedures
Date to be Corrected: December 28,2018

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: 1 PIC was missing a current consent form to contact medical support. through discussion with the manager it was noted that this PIC has PG&T and will require consent from the trustee (This is a repeat contravention)
Corrective Action(s): ensure all PIC's have current consent for medical support forms available
Date to be Corrected: January 8, 2018


Comments

Ots is recommended that all old documentation is removed filed separately and all updated and reviewed documentation is added to the appropriate areas

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
Jan 04, 2018

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