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

FACILITY NAME
Forglen 5452
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
NGIL-7PBVL2
FACILITY ADDRESS
5452 Forglen Dr
FACILITY PHONE
(604) 435-4110
CITY
Burnaby
POSTAL CODE
V5H 3K7
MANAGER
Elmo Jackson

INSPECTION DATE
March 22, 2021
ADDITIONAL INSP. DATE (multi-day)
March 26, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
02:30 PM
DEPARTURE
03:30 PM
ARRIVAL
01:30 PM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this 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/long-term-care-licensing#.XXbB7myos2w for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)
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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: On inspection the LO noted one chair in the dining room had leather seat worn out and peeling off. Of concern is disinfecting the chair appropriately between use.

Corrective Action(s): Ensure all equipment and furnishings are maintained in a safe and clean condition.

Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: 1). A common bathroom on the main floor was found to be very dirty and the staff person assisting with the inspection stated that one PIC was having loose bowel movement.
2). 1 PIC bedroom floor upstairs was observed to be dusty and in need of cleaning. A layer of dust was also found on the stairs leading to the bedroom upstairs. This was brought to the attention of staff person assisting with the inspection.

Corrective Action(s):
Please ensure that all PIC bedrooms and common areas are maintained in clean condition.
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Bleach and other cleaning supplies are kept in the closet that had the doors open.

Corrective Action(s): Ensure safe and secure storage of cleaning agents and chemical products.

Date to be Corrected:

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: 1). The fridge temperature was not documented daily as per the facility policy. The fridge temperature records for the PICs fridge was not recorded consistently for January and February, 2021.
2). The finance record for one person had missing second staff person signatures for one time in February, 2021. The facility policy is for 2 staff to sign for the PIC funds as per the leadership.

Corrective Action(s): Please ensure that policies are implemented by employees.

Date to be Corrected:

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: The substitution list does not appropriately identify the different food group items that were substituted. 3 days substitution list for January and February, 2021 noted only "pizza" as substituted items on the menu.

Corrective Action(s): Please ensure that each menu provides substitutions to be made from the same food group with similar nutritional value.

Date to be Corrected:


Comments

Please note: This report was written off-site due to the Covid-19 visitor restrictions in place, and forwarded to the Licensee. Thank you to all the staff for their assistance with 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
Apr 13, 2021

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