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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

FBES-CR8TKV

FACILITY NAME Victoria Rest Home Ltd.		SERVICE TYPES 120 Mental Health	FACILITY LICENSE # 2504123
FACILITY ADDRESS 731 Queens Ave			FACILITY PHONE (604) 525-2048
CITY New Westminster	POSTAL CODE V3M 1L7		MANAGER Angela Hsiao

INSPECTION DATE April 25, 2023	ADDITIONAL INSP. DATE (multi-day) April 26, 2023		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 11:40 AM	DEPARTURE 02:10 PM	ARRIVAL 11:30 AM	DEPARTURE 12:00 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

STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Two new staff did have the evidence of compliance to TB but not with Province's immunization.
Corrective Action(s): Please ensure that all employees in the community care facility provide evidence of compliance to Province's immunization and tuberculosis control program.
Date to be Corrected: May 10, 2023

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of 6 persons in care (PIC) paper medication administration record (MAR) found PRN medication results were not recorded for 3 PICs and 2 PICs' MAR has missing staff signatures or codes.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 10, 2023

POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: The emergency menu was not available during inspection.
Corrective Action(s): A licensee must have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care
Date to be Corrected: May 10, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: One of 4 PICs has no evidence of compliance to Province's immunization and tuberculosis control programs on file.
Corrective Action(s): A licensee must require all person admitted to community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 10, 2023

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: One person in care's medication stored in the medication cart was expired.
Corrective Action(s): Please ensure to return person in care's medication to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: May 10, 2023

Comments

Update from staff that the abatement of Asbestos still in process and aware of the requirement of Health and Safety plan in any renovations.
The rodent issue has been addressed and monitoring in place.
No changes with the facility's leadership.

Thank you to all the staff for their assistance and cooperation with the completion of this routine inspection.
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 May 10, 2023.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Provide a written response to Licensing	No action required
Due Date May 10, 2023

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