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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-BDYQX7

FACILITY NAME
Twenty Sixth Avenue Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982534
FACILITY ADDRESS
27134 26th Ave
FACILITY PHONE
(604) 856-6097
CITY
Aldergrove
POSTAL CODE
V4W 3N6
MANAGER
Daniel Penner

INSPECTION DATE
July 11, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
10:48 AM
DEPARTURE
02:00 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 & 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, please feel free to the area Licensing Officer.

Contraventions
Previous Inspection - Contraventions observed on FIR #NTJN-B4XQ3W have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
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: Review of 2 of 5 persons in care records (PIC) found that there had been a change in the care and not all documents had been updated to reflect this care change. It was determined that staff were aware of the changes and providing the care necessary for this PIC. One PIC's care plan's fall plan had no significant changes but it was determined that it had not been reviewed since 2017
Corrective Action(s): Ensure that all documents are reviewed and modified if there is a substantial change in the care of PIC's.
Date to be Corrected: August 12, 2019

MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: Review of the medication storage and discussion with the Manager confirmed that the pharmacist had completed an inspection in April 2019 but did not provide documentation to confirm that this had occurred.
Corrective Action(s): Ensure that the facilities supervising pharmacist inspects the medication storage area and provides documentation to the facility manager.
Date to be Corrected: August 12, 2019


Comments

This LO would like to thank the Manger and Staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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
Aug 12, 2019

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