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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-D2P3NV

FACILITY NAME
George Derby Centre
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
3203592
FACILITY ADDRESS
7550 Cumberland St
FACILITY PHONE
(604) 521-2676
CITY
Burnaby
POSTAL CODE
V3N 3X5
MANAGER
Ava Turner

INSPECTION DATE
February 21, 2024
ADDITIONAL INSP. DATE (multi-day)
February 22, 2024
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10
ARRIVAL
01:30 PM
DEPARTURE
03:45 PM
ARRIVAL
09:30 AM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
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). 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
· Policies & 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

Residential Care Regulation
Community Care and Assisted Living Act

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Three of 6 medication rooms have a medication that has no date written when it was opened, this medication can be stored outside the fridge for 28 days.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: February 22, 2024

POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation (CORRECTED DURING INSPECTION): One of 16 persons in care files has no signed restraint consent from the representative or family of the person in care.
Corrective Action(s): Please ensure that there is an agreement to the use of a restraint given in writing by the representative of the person on care or the relative who is closest to and actively involved in the life of the person in care.
Date to be Corrected: February 22, 2024

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: One of 16 persons in care has no wound care plan.
Corrective Action(s): Please ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care.
Date to be Corrected: February 22, 2024

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Five of 16 persons in care has no evidence of compliance to Province's immunization and tuberculosis control programs on file.
Corrective Action(s): A licensee must require all person admitted to community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: March 8, 2024


Comments

Thank you to all the staff for their assistance and cooperation with the completion of this routine inspection.
The findings were discussed with the facility leadership and the report was written and signed at the site.
The copy of the report and risk assessment were provided via email.

Please submit a written response to this routine inspection to Licensing by March 8, 2024.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Mar 08, 2024

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