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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AV6UYJ
FACILITY NAME
Quadling House B		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
AKLN-6AGPWH
FACILITY ADDRESS
820 B Quadling Ave		FACILITY PHONE
(604) 931-3673
CITY
Coquitlam		POSTAL CODE
V3K 2A4		MANAGER
Lily Marian
INSPECTION DATE
January 19, 2018		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.5
ARRIVAL
11:00 AM		DEPARTURE
04:00 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)
If you have any questions regarding this report feel free to contact me at 604 949 7710
Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-AGMQPY have been corrected except for those noted on supplementary pages.
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: 31090 - RCR s.16(3) - A licensee must ensure that the lighting, both natural and artificial, and temperature of a room intended for the private use of a person in care meets the needs and preferences of that person.
Observation: Light in downstairs shower room burned out, replaced during inspection
Corrective Action(s): Please ensure that all lighting is maintained for optimal usage.
Date to be Corrected: done

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Drawer pull missing from bedroom dresser
Corrective Action(s): Please provide a plan to ensure that all furniture is appropriately maintained.
Date to be Corrected: Feb. 1, 2018

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: Medicated prescription skin lotion observed on dresser in PIC room.
Corrective Action(s): Please provide a plan that will ensure that medications meant for self administration are stored securely after use.
Date to be Corrected: Feb. 1, 2018

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: One Care Plan of a new resident was reviewed and found to be missing one weight in four months for a new PIC. No reason was given for the missing weight.
Corrective Action(s): Please provide a plan that will ensure that if there is a reason that the PIC is not weighed, a reason is documented.
Date to be Corrected: Feb. 1, 2018
Comments

Hot water temp was measured at 50.0 degrees C. Manager, new since 2 week start date, was familiarized with the licensing requirement.
Five of seven staff's performance assessment were observed to have been last reviewed in October/November of 2016. There has been has been a staff turn over in the last few months that now appears settled. Please ensure there is a plan to review staff performance as per licensee policy.
A new admission is still missing some records such as consent for calling the Medical/nurse practitioner or ambulance. and the TB status. The new manager is waiting for the information for PIC who was admitted in September.
The menu plan was reviewed. It was noted that there were 2 food groups in one meal. The Canada Food Guide was reviewed with the manager, as well as the intent of the Regulations surrounding Nutrition Monitoring. The manager is intending to build new menus with input from PIC's and staff.
Household cleaning tools, mops and rags were observed in the bathroom bathtub. It is near the front door and is used by 2 residents.
There was damage observed to the walls in the entrance hall and the northwest bedroom. Thick foam has been applied to the walls above the bed and beside the door. The manager is actively seeking strategies to prevent the damage caused by a new PIC.
This home is very attractive and can be seen to reflect the personalities of the residents. It is tidy and well organized.
I would like to thank the staff who assisted with the inspection.
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
Jan 19, 2018
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Click here for a description of each "Category" of violation displayed.