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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BLGTRS

FACILITY NAME
Gray House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203598
FACILITY ADDRESS
6957 Gray Ave
FACILITY PHONE
(604) 436-3970
CITY
Burnaby
POSTAL CODE
V5J 3Y9
MANAGER
Dale Reynoldson

INSPECTION DATE
February 04, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.75
ARRIVAL
11:15 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
5

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 :http://www.gov.bc.ca/residentialcarefacility
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

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

Observed Violations
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Of the staff files reviewed, it was identified that 2 did not have recent performance evaluations completed. Facility policy requires evaluations to be completed on an annual basis and the evaluations viewed were dated 2015 and 2017 respectively.
Corrective Action(s): Ensure that the performance of each employee is regularly reviewed.
Date to be Corrected: 28 Feb 2020

RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation: Upon review of care plans it was noted that 2 persons in care (PIC) are using a restraint. There was no documentation in place for either PIC to indicate that they are being monitored while using the restraint.
Corrective Action(s): Ensure that all PICs using a restrain are monitored during the restraint.
Date to be Corrected: 05 Feb 2020

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Upon inspection of the menu binder it was observed that the menu checklist was for only one week of the entire menu and it was dated 2018. It was discussed with the facility manager at the time of the inspection that best practice is for each week of the menu to be checked to ensure that it complies with the nutritional requirements of the Canada Food Guide. The meals and more checklist was suggested as an appropriate tool to use for this purpose.
Corrective Action(s): Ensure that nutrition care is monitored and ensure that the menus comply with the Canada Food Guide
Date to be Corrected: 28 Feb 2020


Comments

Thank you to the staff of Gray House for their assistance in completing this inspection. Please feel free to contact your Licensing Officer with any questions you may have.

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
Feb 14, 2020

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