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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AV4TXK

FACILITY NAME
Mundy Street Residence
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1020005
FACILITY ADDRESS
316 Mundy St
FACILITY PHONE
(604) 931-7123
CITY
Coquitlam
POSTAL CODE
V3K 5M4
MANAGER
Kristin Kavanagh

INSPECTION DATE
January 16, 2018
ADDITIONAL INSP. DATE (multi-day)
January 23, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
02:00 PM
DEPARTURE
05:00 PM
ARRIVAL
01:15 PM
DEPARTURE
02:00 PM
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-AHXN75 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: The lighting in the living room is very dim. There is little natural light entering the room. The manager states the major source of lighting, missing 50% of lights, is broken and she is unable to safely replace the light bulbs in the fixture. The light level makes activities other than TV watching difficult, especially in winter months..
Corrective Action(s): Please provide a plan that will ensure the appropriate levels of lighting are available in the living room for PIC use.
Date to be Corrected: Jan. 26, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The flooring beneath 2 of the dining room chairs have been worn significantly to the substrate below the finished surface of the tiles. There are 7 tiles involved under chairs and 2 damaged tiles around the heat register. Various methods of improving the floor appearance were discussed.
Corrective Action(s): Please provide a plan that will ensure that flooring is maintained in good repair.
Date to be Corrected: Jan 26, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Emergency preparation supplies were reviewed for outdated items in the outside storage area. The bottom of the container was flooded by approximately 2-3 inches from a side-lying water container.
Corrective Action(s): Please provide a plan that will confirm that appropriate measures are in place to ensure the integrity of the emergency supplies as well as the currency of expiry dates.
Date to be Corrected: Jan. 26, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31580 - RCR s.30(a) - A licensee must ensure that all bathrooms have (a) a door, equipped with a lock that can be opened from the outside in the case of an emergency.
Observation: The lock on a sliding pocket door appears disabled.
Corrective Action(s): Please provide a plan that will ensure that the bathroom doors can lock as well as be unlocked from the outside in the case of an emergency.
Date to be Corrected: Jan 26, 2018

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Two outdated medications were found in the PRN container of one resident.
Corrective Action(s): Please provide a plan that will ensure that medications are reviewed on a regular basis to ensure that outdated medications are returned to the pharmacy.
Date to be Corrected: Jan 16, 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: Only one care plan was reviewed. It was observed to be missing 2 monthly weights, with no reason written for the absence of record.
Corrective Action(s): Please ensure that weight monitoring is done monthly, or that a reason is documented for missing the recording of weight.
Date to be Corrected: Jan. 26, 2018


Comments

The height and weight on admission is missing for the single care plan that was reviewed. This is a repeat contravention from last year. There was discussed at the time for acceptable height. and weight. on admission if the actual data was no longer available. The manager was unable to locate the information but was sure it was corrected as per the plan for the last Routine Inspection response. Manager will provided confirmation before Jan. 26, 2018.
A new fridge-freezer is installed in the kitchen. The temperature of the freezer portion was -17.5 degrees C. Acceptable freezer storage is identified as -18 to -22 degrees C per Food Safe. Please ensure that the temperature is monitored to ensure it is appropriate for food storage.
The manager states that during the summer last year there had been an anonymous concern raised about the heat in the building. This year a very large shading tree has been removed from the North West side of the building. Since the issue was raised last year the manager has initiated the following:
-all the rooms have fans,
-the staff have received education about overheating of residents, symptoms to observe for, fluids for residents to prevent dehydration
-staff know about rotating the window coverings for best heat management in summer weather
- the sky lights x 2, on the southern exposure over the dining room table, were identified as having the capability of opening. This could be helpful in moderating household temperature on hot days. Unfortunately the pole extensions meant to activate the skylight openings have been lost over time and the manager was not aware of the location.

This facility is clean, well organized and tidy. The rooms reflect the choices and personalities of the residents. I'd like to thank the staff and manager for assistance with this 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 26, 2018

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