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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-CC7RR6

FACILITY NAME
Creation House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
NGIL-BVHPFT
FACILITY ADDRESS
4103 Irmin St
FACILITY PHONE
(604) 435-9544
CITY
Burnaby
POSTAL CODE
V5J 1X6
MANAGER
Peter Brodnan

INSPECTION DATE
March 01, 2022
ADDITIONAL INSP. DATE (multi-day)
March 04, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
02:00 PM
DEPARTURE
04:00 PM
ARRIVAL
02:30 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: 1 PIC who receives crushed medications did not have procedure of crushing medications available to the staff person assisting with the inspection. A mortar and pestle was stored in the medication cabinet for crushing the medications.

Corrective Action(s): Please ensure that MSAC provides clear procedures in respect to handling and administration of the PIC's medications.

Date to be Corrected: March 17, 2022

CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 1/4 PICs' care plan did not include information to guide/instruct staff to redirect PIC as appropriate concerning an on-going behavior. Staff are aware about prompting PIC but the care plan did not have this information.

Corrective Action(s): Please ensure that the care plan is reviewed and modified to meet the needs and preferences, and is compatible with the abilities, of the PIC who is the subject of the care plan.

Date to be Corrected: March 17, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: 1/4 PICs receive 2-3 monthly supplies of prepared meals at one time and the staff heat and serve these meals at the PIC's request. There is no date of preparing/packaging indicated on these food items that the PIC is served.

Corrective Action(s): Please ensure that all food is safely stored, handled and served.

Date to be Corrected: March 17, 2022


Comments

Thank you to all the staff for their assistance with this inspection. All staffing requirement checklist was sent by the HR to the facility for review during this routine inspection. The facility manager is on vacation and manager designate was available for this inspection.

Should any further clarification or questions arise regarding this report, 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 LicensingNo action required
Due Date
Mar 17, 2022

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