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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JBAY-C3JTMU

FACILITY NAME
Maple Ridge Seniors Village
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9VR4
FACILITY ADDRESS
22141 119th Ave
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Bianca Goldberg

INSPECTION DATE
May 28, 2021
ADDITIONAL INSP. DATE (multi-day)
May 31, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.08
ARRIVAL
10:00 AM
DEPARTURE
12:00 PM
ARRIVAL
11:00 AM
DEPARTURE
12:05 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

A follow up inspection to Routine Inspection CJOS-BYYVHT, dated 05/Mar/2021, was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).

The following care systems were reviewed during this inspection:
- Staffing
- Policies and Procedures
- Hygiene and communicable disease control

For resources for licensees, links to the Legislation (CCALA and RCR), and Residential Care Facility Inspection Reports posted online go to: www.fraserhealth.ca/residentialcare

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
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 review of staff file records found that there were 2 staff files that did not have evidence of required certificates and 15 staff files that did not have evidence of required training. Although this is a repeat contravention, management has taken steps to address this issue including sending out letters to staff to obtain the missing information and creating an audit binder to track when the requested information has been received.
Corrective Action(s): Ensure that employee files contain copies of any diplomas, certificates, or other evidence of the person's training and skills.
Date to be Corrected: June 30, 2021

STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: A review of staff file records found that there were 4 staff files that did not have evidence of TB screening and 4 staff files that did not have evidence of immunization records. Although this is a repeat contravention, management explained that they were under the impression that every staff is required to have a TB test as opposed to a TB screening. Going forward, management will ensure that every staff completes a TB screening and a TB test when the screening deems it necessary.
Corrective Action(s): Ensure that all employees provide evidence of compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: June 30, 2021


Comments

A review of staff schedules and call out sheets determined that over the past month there were 62 shifts that could not be filled; however, management reports that staffing levels were not short given that they currently have 10 empty beds and given that Fraser Health provided staffing support due to the facility being in enhance monitoring. Although this is not a contravention of the Residential Care Regulation (RCR) s. 42(1)(a) as the facility was not short staffed, of concern is facility's ability to maintain staffing levels when enhanced monitoring is over and Fraser Health is no longer providing staffing support. Facility management did admit that maintaining staffing levels is a struggle as the Single Site Order has made it difficult to recruit new staff. Management also relayed that, during times of quarantine, some staff who may have picked up shifts or who may have taken overtime shifts were unable to do so in order to adhere to Infection Prevention Control measures. Management is taking steps to recruit and hire new staff and will continue to do this. Since the last routine inspection on March 5, 2021, management has hired 20 new staff to help address the concerns around staffing.
After meeting with the leadership team, it is evident that they are committed to ensuring that Maple Ridge Seniors Village is complying with the RCR and it is their desire to maintain compliance moving forward. Thank you to all the staff for their assistance with this inspection.
For their reference and use, facility management was sent copies of Fraser Health's TB Screening for Staff and Employee Immunization Record forms.
Please submit a written response by June 15, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.
This inspection report was not signed by management as it was reviewed with management over the telephone and sent via email to the site to reduce the amount of time the licensing officer had to spend on site as per COVID-19 prevention measures.

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
Jun 15, 2021

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