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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AE7SKW

FACILITY NAME
Sakura House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081380
FACILITY ADDRESS
566 Schoolhouse St
FACILITY PHONE
(604) 939-4342
CITY
Coquitlam
POSTAL CODE
V3J 5P3
MANAGER
Bree MacColl

INSPECTION DATE
September 27, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.5
ARRIVAL
09:45 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

This is an unannounced Annual Routine Inspection to assess facility compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR). This inspection was conducted in the presence of the manager and one staff.
The following sections were audited:
-Licensing
-Physical Facility
-Staffing
-Policy and Procedures
-Care and Supervision
-Medication
-Hygiene an Communicable Disease
-Nutrition and Food Services
-Program
-Records and Reporting
A copy of the Licensing Officer's Reference Guide to Residential Care Database Coding and and abbreviated facility records checklist was provided to the manager

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-A4NQZN have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
POLICIES AND PROCEDURES: 33320 - RCR s.85(2)(b) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (b) the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Observation: Clear reference to orientation of new staff to the RCR and CCALA were not identified. Please ensure that the policy for orientation meets the intent of the above legislation.
Corrective Action(s): Please provide a plan that will identify how the above legislation will be met. Corrected at inspection.
Date to be Corrected: Oct. 17, 2016


Comments

The Fridge freezer was measured at 13.5 degrees Celsius. The daily record posted on the fridge showed consistent readings of less than 20 degree Celsius. It appears to meet the intent of the regulation.
The narrow dividing wall between the entrance to the shower room and the shower is peeling paint, the fence between the driveway and the backyard is getting wobbly and a horizontal 2x4 stabilizing topper to the fence latice on the right of the gate is missing. The manager states all these issues are on the BC Housing list awaiting repair.
A spread sheet for staff qualifications was provided to this LO by the manager. Some of the information was not available. Please ensure that the spreadsheet provided reflects the current status of the staff and that expiry dates for CRC (Criminal record checks), First Aid, and dates of most recent performance reviews are clearly identified for inspection.
Restraints in the form of bed rails and seat belts have not been reviewed since 2014 for one PIC. Since there has been recent change in the CCALA and RCR with respect to restraint, this issue will be reviewed and forwarded to the manager.
Week 3 of the spring/summer menu was reviewed. Evening snacks were observed to contain only 1 food group. The manager states that there are 2/3 residents who are struggling with weight gain, and that one of the FH Licensing Dietitian workshops had indicated that in this instance it was reasonable to offer only one food group in the evening. The LO will confirm the details of this issue and respond to the manager.
The substitution list has had no entries since May 20, 2016. The manager states that there have been no substitutions in that time because the menu is closely followed. It is important to note that celebration meals such as, birthdays, Christmas, Easter etc are considered substitutions in the event their contents are not consistent with the menu.
This facility appears clean and well organized. I would like to thank the staff and the manager for their assistance with this inspection.


Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Oct 17, 2016

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