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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BHWU9D

FACILITY NAME
Carson House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203593
FACILITY ADDRESS
5155 Carson St
FACILITY PHONE
(604) 435-8904
CITY
Burnaby
POSTAL CODE
V5J 2Z1
MANAGER
Chicky Padron

INSPECTION DATE
November 14, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
12:00 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XXbB7myos2w for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection -
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: 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: Upon inspection of this home a number of areas requiring repair were observed. Included are:
- The kitchen counter tops had a few areas that were worn down. Of concern is the ability to sanitize this area appropriately.
- There were a number of areas on the walls and doors where the paint was worn or chipped and required painting. Several areas on the walls appeared to have been patched and now require paint.
- There was rust on the baseboard heaters.
-The paint kitchen window sill was peeling.
Corrective Action(s): Ensure that all rooms are maintained in a good state of repair.
Date to be Corrected: Novemebr 29, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Upon inspection of the home it was observed that there were areas that appeared to be unclean Included are:
- The stove, specifically the top of the oven door.
- The floors had numerous areas with visible dust and debris.
- The walls in one bathroom required cleaning.
- All bathrooms in general require intensive cleaning, including cleaning the tubs, toilets, sinks and mirrors.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a clean condition.
Date to be Corrected: November 29, 2019.

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: It was observed that there were 2 items stored in the freezer that were not in their original packaging and were not labelled and dated.
Corrective Action(s): Ensure that all food is safely stored.
Date to be Corrected: November 22, 2019.

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 review of all nutrition records it was observed that there is not a menu audit in place for the current Fall/Winter menu. The Spring /Summer menu audit is in place, however it is not complete.
Corrective Action(s): Ensure there are records in place to reflect the results of monitoring of the food services and nutrition care.
Date to be Corrected: November 29, 2019


Comments

This home does have thermometers in each if its fridges and freezers. It was noted however, that the temperatures are not being documented. In order to effectively monitor the temperatures and ensure that they remain in the safe zones, it was suggested that a record of temperatures be kept. Typically a sheet is fastened to the fridge for the purpose of recording temperatures.

Thank you to the staff for their assistance in completing this inspection. Should you have any questions or concerns related to this inspection, please contact your Licensing Officer.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Nov 29, 2019

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