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

Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

VDAN-AT7S9V

FACILITY NAME Wingate House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081122
FACILITY ADDRESS 1234 Winslow Ave			FACILITY PHONE (604) 931-3802
CITY Coquitlam	POSTAL CODE V3J 2G2		MANAGER Lorraine Fraser

INSPECTION DATE November 17, 2017	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.75
ARRIVAL 01:15 PM	DEPARTURE 05:00 PM	ARRIVAL	DEPARTURE	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) If you have any questions regarding this report feel free to contact me at 604 949 7710

Contraventions

Previous Inspection - Contraventions observed on FIR #VDAN-AGCRFE have been corrected except for those noted on supplementary pages.

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan. Observation: Fire drill reports were inconsistent for the previous year. Three months were missing documentation of completing fire drills. Corrective Action(s): Please ensure that fire drill training occurs according to licensee policy. Date to be Corrected: Dec. 15, 2017 POLICIES AND PROCEDURES: 33290 - RCR s.85(2)(a)(i) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (a) if the licensee provides a type of care described as Long Term Care, fall prevention, including (i) an assessment of the nature of the risks that may result in persons in care falling in the community care facility. Observation: One PIC is unsteady on his feet. There was a non reportable incident form from May that identifed a fall for this person. An assessment of his falls risk could not be found in his care plan. Corrective Action(s): Please ensure that persons who are vulnerable to falls are appropriately assessed Date to be Corrected: Dec. 15, 2017 HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene. Observation: Products were found in the east bathroom that were not labelled. Corrective Action(s): Please ensure that all personal products are identified for the person they are intended. Date to be Corrected: Dec. 15, 2017 RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month. Observation: Weights were observed to be inconsistently recorded for one PIC, no reason for absent weights was recorded. Corrective Action(s): Please provide a plan that will ensure that weight for all PIC's are appropriately recorded or a reason given. Date to be Corrected: Dec. 15, 2017

Comments

Emergency preparation, the locked trunk in the shed containing emergency supplies could not be opened as location of the key was not known to manager. Manager states there is a designated staff who manages the emergency response resources for the facility. Please provide a plan that will ensure that management of the emergency supplies is monitored and access to the supplies is readily available in the event of a disaster. When new staff arrived for afternoon shift, access to the emergency food bin was accomplished, some newly outdated products were observed and reported by the manager. The emergency resources will be discussed at the next staff meeting. The finances of one PIC were $5.75 deficient. There was no receipt to indicate the absence of the funds. There were also 4 checks found in one PIC's zipper bag, 2 checks were current, but not used. There is one staff designated to manage the funds of all the PIC's. The manager and staff provided an explanation for the funds and the checks before the end of the inspection. The licensing officer had difficulty raising the attention of staff in the house due to the fact the door bell was not working. Please respond with a plan for resolution of this problem in the response. There will some painting, replacement of baseboards and replacement of the East bathroom floor. The manager will submit a health and safety plan for approval of this LO in advance of the planned work. The Policies and Procedures were reviewed at the sister facility yesterday. Both facilities use the same P&Ps and they will not be reviewed today. Repeat observations from the previous routine inspection were, 1. missing fire drills and 2. no falls risk in the care plan. The facility is very nicely organized and decorated. The PICs appear relaxed in their interactions with the staff, making jokes and requests and seeming to enjoy themselves. Thank you to staff and PICs who were present and participated in this inspection.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Dec 15, 2017

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