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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-AY6S7K
FACILITY NAME
The Madison		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YUG4
FACILITY ADDRESS
1399 Foster Av		FACILITY PHONE
(604) 936-9231
CITY
Coquitlam		POSTAL CODE
V3J 2N1		MANAGER
Annie Kinamore
INSPECTION DATE
April 24, 2018		ADDITIONAL INSP. DATE (multi-day)
April 25, 2018		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10
ARRIVAL
10:00 AM		DEPARTURE
04:00 PM		ARRIVAL
09:30 AM		DEPARTURE
01:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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). 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
· Physical Facility
· Staffing
· Polices & 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
Links to the Legislation (CCALA & RCR)
Contraventions
Previous Inspection - Contraventions observed on FIR #TMA-005 (RCS Inspection 2017) have been corrected.
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: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: The facility tub rooms are required to be locked when not in use as cleaning chemicals are stored in them. During the inspection 1 tub room was noted to have been left unlocked creating the potential hazard of a PIC accessing the cleaning chemicals.
Corrective Action(s): Please ensure all cleaning chemicals are stored in a safe and secure manner.
Date to be Corrected: April 30 2018
Comments
Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.