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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-BCGSUD

FACILITY NAME
The Terraces at Evergreen
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0963001
FACILITY ADDRESS
1550 Oxford St
FACILITY PHONE
(604) 536-3344
CITY
White Rock
POSTAL CODE
V4B 3R5
MANAGER
Tami Johnson

INSPECTION DATE
May 24, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.5
ARRIVAL
09:30 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
251

Introduction

A routine inspection was conducted in the presence of the Administrator to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- 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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2CWtTpKipp for:

- Additional resources, and
- Links to the legislation (CCALA and RCR).

Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: A random review of four staff files indicated a staff did not have their criminal record check completed on file from the Ministry for Public Safety and Solicitor General.
Corrective Action(s): Please ensure where required staff have their criminal record check completed and on file.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: A random review of four staff files indicated a staff did not have references on their file.
Corrective Action(s): Please ensure staff have references on file where required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32030 - RCR s.37(1)(c) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (c) a record of the person's work history.
Observation: A random review of four staff files indicated a staff member did not have their work history noted on file.
Corrective Action(s): Please ensure all staff where applicable have their work history noted on their file.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: A random review of four staff files indicated a staff did have their diploma/certificate regarding their current employment in the role they currently do.
Corrective Action(s): Please ensure where applicable all staff have copies of their diplomas/certificates on file.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: A review of the care planning system indicated a person in care did not have a oral care plan in-place.
Corrective Action(s): Please ensure all persons in care have a care plan around oral care in-place.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: A review of the care planning system indicated that a person in care did not have a fall risk assessment in-place.
Corrective Action(s): Please ensure all persons in care have a fall risk assessment in-place.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.


Comments

Volunteer files:

- A discussion took place with the staff that oversees the volunteers. The Tuberculosis and Immunization Guideline for staff will be implemented moving forward for volunteers including tuberculosis and immunization status. In addition references are documented and the staff that oversees the volunteers will be ensuring written references are documented on file. Please let the writer know the plan to address this moving including time lines for implementation for these items.

In-services for dietary staff:

- A binder that has in-service records/participation records was reviewed. In-services for example occurred in March and February 2019; November 2018; April 2018; February 2017; July 2016; June 2016 and April 2015. The writer will e-mail to the Administrator a sample in-service schedule developed by another facility to assist in developing one for the Terraces at Evergreen. Please let the writer know when a set schedule will be developed that has in-services held on a regular basis.

Thank you for your time to complete today's inspection. If there are any questions, please contact your Licensing Officer.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Due Date
May 31, 2019
Approximate Follow Up Date
28 Jun, 2019

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