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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KTRR-BZGVFD
FACILITY NAME
Evergreen House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
LBAA-8VPVD3
FACILITY ADDRESS
638 Kemsley Ave		FACILITY PHONE
(604) 931-0974
CITY
Coquitlam		POSTAL CODE
V3J 3Z3		MANAGER
Kate Mireku
INSPECTION DATE
March 26, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
11:30 AM		DEPARTURE
02:45 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was conducted 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 (DLSOP). 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
· Hygiene and Communicable Disease Control
· Physical Facility
· Medication
· Staffing
· Nutrition and Food Services
· Policies and Procedures
· Programming
· Care and Supervision
· 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 CCFL website at :http://www.gov.bc.ca/residentialcarefacility
· Additional resources, and
· Links to the Legislation (CCALA and 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
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: It was observed that menu audits included servings of grain products and meat and alternatives that were not observed on corresponding menus.
Corrective Action(s): Ensure that all menu audits and menus are based on and meet the requirements of Canada's Food Guide.
Date to be Corrected: April 14, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: The cover for the toilet tank in the tub room was propped open against the wall behind the toilet, exposing the contents of the tank. Staff indicated the flush component was awaiting replacement by BC Housing.
Corrective Action(s): While awaiting the repair of equipment, ensure equipment used by persons in care is maintained in a safe and clean condition.
Date to be Corrected: Corrected at time of inspection.

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: The medication storage was unlocked and the key was observed hanging from the lock. Powdered medication for two PICs were stored together.
Corrective Action(s): Corrected at time of inspection.
Date to be Corrected: Corrected at time of inspection.

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: 1 of 2 PIC files reviewed had not been updated to include substantial changes to a PIC’s recreation and leisure care plan.
Corrective Action(s): Ensure recreation and leisure plans are reviewed and revised due to the current circumstances.
Date to be Corrected: April 14, 2021


Comments

Community Care Facilities Licensing (CCFL) would like to thank staff and management for their time and assistance in completing this routine inspection.
In order to minimize time spent on site due to the COVID-19 pandemic, this report was reviewed with facility management via phone conference and a copy emailed to management.
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 14, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.