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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AX5S67

FACILITY NAME
Magnolia Gardens
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
MLAO-9ZTU77
FACILITY ADDRESS
5840 Glover Rd
FACILITY PHONE
(604) 514-1210
CITY
Langley
POSTAL CODE
V3A 9K3
MANAGER
Sue Wilson

INSPECTION DATE
March 23, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
10:00 AM
DEPARTURE
02:30 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 - Not Applicable
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: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: Audit of 4 person in care bedrooms and discussion with the manager, a safe, secure place in which the person in care may store valuable property is not provided or offered.
Corrective Action(s): Ensure persons in care are offered, at no cost to the person in care, with bedroom furnishings, including a safe, secure place in which the person may store valuable property.
Date to be Corrected: April 27, 2018

POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Review of emergency food supplies, items including soups and juices were expired, dates showing between 2016 and 2017.
Corrective Action(s): Ensure all supplies required in the emergency plan are updated to ensure response to and recovering from any emergency will be appropriately implemented.
Date to be Corrected: April 27, 2018

RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: In 1 of 4 care person's charts reviewed, the room number did not reflect the current bedroom that the person in care was residing.
Corrective Action(s): Ensure all records are current.
Date to be Corrected: April 27, 2018.


Comments

Discussion with the manager regarding securing the medication cart when nursing staff leave the cart to administer the medication. Although the policy does not speak to this practice of securing the medication cart each time, licensing discussed the potential for access to the unsecured medications should the nurse potentially need to deal with a medical emergency and the cart is no longer in the line of site for the nurse. Licensing recommends a discussion with the Medication Safety and Advisory Committee to review this process.

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
Apr 27, 2018

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