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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

JSTT-D49MU5

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 Colleen Saunders

INSPECTION DATE April 12, 2024	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2.5
ARRIVAL 10:30 AM	DEPARTURE 01:20 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), 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 include: · 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

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide. Observation: Upon observation of the menu, only water and Frozen yogurt are being offered for AM snack, and only milk or water are being offered for PM snack. Snacks are not being offered at least 2 times per day with 2 food groups. Documentation in one PIC's file mentions reducing snack for Two PIC's, however this was not dated and does not appear to reflect the current up to date circumstances for both PIC's. Corrective Action(s): At least 2 nutritious snacks are to be offered containing at least 2 food groups, per day, unless the PIC's care plan has reasons documented otherwise. Date to be Corrected: April 19 2024

Comments

Food substitutions and snacks were discussed with staff. Thank you to staff for providing assistance during this inspection.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Apr 19, 2024

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