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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JFUR-CRNS5K
FACILITY NAME
Hylan Home		SERVICE TYPES
150 Acquired Injury
FACILITY LICENSE #
0782552
FACILITY ADDRESS
32223 Hylan Ave		FACILITY PHONE
(604) 850-8122
CITY
Abbotsford		POSTAL CODE
V2T 1S8		MANAGER
Lydia Valle Nguyen
INSPECTION DATE
May 09, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
10:15 AM		DEPARTURE
02:15 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
9
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 as part of a routine inspection:
- Licensing
- Physical Facility
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting


As part of this routine inspection, a facility risk assessment tool is completed. The risk assessment includes contraventions 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/residentialcare for:
-Additional resources and
-Links to the Legislation (CCALA & RCR)
Contraventions
Previous Inspection - Contraventions observed on FIR #KBEL-CQCSA9 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: 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 Medication Administration records found that one Person in care record did not include a follow up to indicate if the medication administered was effective or not.
Corrective Action(s): Please ensure that you comply MSAC policies including ensuring a follow up to PRN medication is documented.
Date to be Corrected: 16 May 2023

CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of weight records found there to be a person in care with a 15lb weight increase within a 1 month period. Of concern is the dietician has not been notified as required.
Corrective Action(s): Please ensure if there are any significant increase or decrease to weights, that a dietician is consulted.
Date to be Corrected: 16 May 2023
Comments

This report and risk assessment was reviewed in person with facility manager, and an emailed copy was provided. Discussion with the licensee surrounding increasing capacity and informed of what the process would include. Thank you for the staff for your assistance today.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
May 16, 2023
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Click here for a description of each "Category" of violation displayed.