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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-BHWNM9

FACILITY NAME
Hylan Home
SERVICE TYPES
150 Acquired Injury
FACILITY LICENSE #
0782552
FACILITY ADDRESS
32223 Hylan Ave
FACILITY PHONE
(604) 850-8122
CITY
Abbotsford
POSTAL CODE
V2T 1S8
MANAGER
Lydia Valle Nguyen

INSPECTION DATE
November 14, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
10:00 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections and investigations include the following: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & 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 www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA & 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
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 (CORRECTED DURING INSPECTION): on review of 3 care plans, one person in care did not have a completed TB screening form.
Corrective Action(s): A licensee must require all persons in care to comply with the Province's immunization and TB control program.
Date to be Corrected: corrected on inspection.

MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: one PRN medication for one person in care did not have a phamacy label attached.
Corrective Action(s): A licensee must ensure that a pharmacist packages all medication.
Date to be Corrected: November 21, 2019


Comments

-Licensing officer (LO) recommends adding additional water to the emergency supplies, as only one case of water was available in case of emergency.
-LO recommends removing items not being used by the facility, and old furnishings from the storage and garage areas. Manger plans set up removal of old items by December 1, 2019.

LO would like to thank the manager and staff for their cooperation during this routine inspection.

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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