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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-CJC4U7
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
September 16, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
10:00 AM		DEPARTURE
01:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSOP). 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:
o Licensing
o Hygiene and Communicable Disease Control
o Physical Facility
o Medication
o Staffing
o Nutrition and Food Services
o Policies and Procedures
o Programming
o Care and Supervision
o 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
o Additional resources, and
o Links to the Legislation (CCALA and RCR)
Contraventions
Previous Inspection - Contraventions observed on FIR #KTRR-C3KUEH have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
MEDICATION: 36060 - RCR s.68(2)(c) - A licensee must appoint a supervising pharmacist to (c) consult with employees respecting medication interactions and other problems related to medication.
Observation: Upon inspection of the facility's medication administration systems, it was determined that there was no evident to support that a Medication Safety Advisory Committee meeting held within the last 2 years. The most recent meeting minutes were from 2020.
Corrective Action(s): Please ensure the supervising pharmacist consults with employees respecting medication interactions and other problems related to medication.
Date to be Corrected: September 30, 2022

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of the menu and nutrition monitoring records found there to be missing a menu checklist. The importance of completing the menu checklist was discussed with the facility staff. Of concern is the nutritional elements have not been audited to ensure the menu meets the nutritional needs of the persons in care, as per the Canada Food Guide.
Corrective Action(s): Keep a record of the results of food services and nutrition care.
Date to be Corrected: September 30, 2022
Comments

Resources shared with the Licensee include the following:
Meals and More Manual
Meals and More forms

Thank you to the staff and residents of this home for welcoming me and assisting with this inspection. This report was written off-site and an email copy was provided.
The inspection findings were discussed with facility staff and the Team Lead.
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
Sep 30, 2022
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Click here for a description of each "Category" of violation displayed.