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
SCLY-ADMSR8

FACILITY NAME
Fletcher 1
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081368
FACILITY ADDRESS
12062 Fletcher St
FACILITY PHONE
(604) 463-7118
CITY
Maple Ridge
POSTAL CODE
V2X 6K9
MANAGER
Emily Fowle

INSPECTION DATE
September 09, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
11:30 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care 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
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· 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 www.fraserhealth.ca/your_environment/ccfl for:
Additional resources, and
Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR #NTJN-A2CRMB 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The bathtub jets do not work and there is paint chipping around the outside of the tub. The manager stated that BC Housing has approved a new tub and should get a new one soon. This is a REPEAT contravention.
Corrective Action(s): Please ensure that the bathtub is in good working order.
Date to be Corrected: September 30, 2016

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: Review of the physical facility found the following:
-The baseboards have scratches and paint chips from the wheelchairs scrapping them.
-The walls in the laundry room and hallways have paint chips.
Corrective Action(s): Please ensure that the physical facility is maintained in a good state of repair.
Date to be Corrected: September 30, 2016

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: Review of the medication administration record (MAR) and blister packs found that at least 2 medications had been given, but not initialed for in the MAR. Also, at least 3 medications had been given from the blister packs, but the staff did not initial the blister pack after dispensing them.
Corrective Action(s): Please ensure that staff comply with the medication safety and advisory committee policies and procedures.
Date to be Corrected: September 9, 2016

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: Two Person in Cares (PIC) had oral care plans that had not been reviewed since 2014 and 2015. There was documentation showing that they have been to the dentist and the manager stated that there had been no change to their care plan.
Corrective Action(s): Please ensure that each PIC has their oral care plan reviewed and if necessary modified each year.
Date to be Corrected: September 30, 2016

RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: Review of 3 PICs files found that admission height and weight have not been recorded.
Corrective Action(s): Please ensure that each PIC has their admission height and weight recorded.
Date to be Corrected: September 30, 2016


Comments


Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Sep 30, 2016

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