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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AGEUCH

FACILITY NAME
Oriole Lodge
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
0703865
FACILITY ADDRESS
32539 Oriole Cres
FACILITY PHONE
(604) 504-7549
CITY
Abbotsford
POSTAL CODE
V2T 4C7
MANAGER
Tisha Ilapogu

INSPECTION DATE
December 07, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
11:30 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: The laundry facility does not have a slip resistant floor surface. The laundry facility is used by all persons in care.
Corrective Action(s): Ensure laundry facilities have a slip resistant floor surface as it is used by persons in care.
Date to be Corrected: January 6, 2017

POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: The medication policy states the pharmacist inspects the medication area at least four times a year. It was stated by the manager the medication area is inspected one time a year. Although this policy has been reviewed by the manager in a timely manner, it has not been revised to reflect current practice. The medication room inspection has been occurring yearly in review of the last three years.
Corrective Action(s): Ensure policy is revised accordingly
Date to be Corrected: January 6, 2017.

RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: The height of persons in care is not recorded upon admission.
Corrective Action(s): Ensure height of each person in care is recorded on admission.
Date to be Corrected: January 6, 2017


Comments

An interim manager will be starting approximately January 9th, 2017 for 10 months. The new manager is in the process of being oriented and the licensee will forward the amendment form and declaration form once required documentation is in place.

The following was discussed with the manager:
- It is recommended review of medication policies and procedures are added as a standing item for the medication safety and advisory committee meetings.

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 06, 2017

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