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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-C2WMD7

FACILITY NAME
Goodlad House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3283073
FACILITY ADDRESS
7912 Goodlad St
FACILITY PHONE
(604) 521-0947
CITY
Burnaby
POSTAL CODE
V5E 2H9
MANAGER
Emily Seselja

INSPECTION DATE
May 10, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:30 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
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). 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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo for:

· Additional resources and
· Links to the Legislation (CCALA & 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
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Three staff files reviewed, one staff person CRC renewal was required last month. This application has been submitted and results pending.
Corrective Action(s): CRC must be up to date
Date to be Corrected: May 28, 2021

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: There were 2 incidents where the PRN effectiveness was not documented which is required as per the Medication Policy and Procedure
Corrective Action(s): Please ensure staff comply with the Policies and Procedures
Date to be Corrected: ongoing

CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Health Care Plan for one PIC has not been updated since September 2019
Corrective Action(s): Please ensure care plans are reviewed at least once each year.
Date to be Corrected: June 4, 2021


Comments

Discussion regarding updating some possible information pertaining to requirements of use of residents.
Please provide a written response to how the above coded violations will be addressed by May 20, 2021.
Due to the COVID Pandemic, the report was written offsite, but the inspection was discussed with the Manager who was on site at the time of the inspection.
Please also ensure the Licensee contact is made aware of this inspection

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
May 20, 2021

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