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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CUWV56

FACILITY NAME
Fair Haven Burnaby Lodge
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
3200045
FACILITY ADDRESS
7557 Sussex Ave
FACILITY PHONE
(604) 435-0525
CITY
Burnaby
POSTAL CODE
V5J 3V6
MANAGER
Joy Parsons

INSPECTION DATE
August 21, 2023
ADDITIONAL INSP. DATE (multi-day)
August 22, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.5
ARRIVAL
12:50 PM
DEPARTURE
03:20 PM
ARRIVAL
10:55 AM
DEPARTURE
02:55 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). 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
· Policies & 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

Residential Care Regulation
Community Care and Assisted Living Act

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: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: One servery refrigerator temperature was not recorded 10 times in August 2023. One person in care's bathing facility was left open.
Corrective Action(s): A licensee must ensure that policies are implemented by employees.
Date to be Corrected: September 5, 2023

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: Three of 12 care plans were not reviewed and modified.
Corrective Action(s): Please ensure that each care is reviewed and, if necessary, modified at least once each year.
Date to be Corrected: September 5, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Two unlabelled plate of food covered in cling wrap were stored in second floor servery. An unlabelled sandwich in a food bin and 2 plates of pureed food covered in cling wrap were found in the kitchen's refrigerator.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: August 22, 2023


Comments

Thank you to all the staff for their assistance and cooperation with the completion of this routine inspection.

A discussion with the facility leadership regarding MSAC policies and procedures to review with nurses.
The findings were discussed with the facility leadership and the report was written and signed at the site.
The copy of the report and risk assessment were provided via email.

Please submit a written response to this routine inspection to Licensing by September 5, 2023.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Sep 05, 2023

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