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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SRAO-BEERAW

FACILITY NAME
58th Avenue Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782286
FACILITY ADDRESS
29172 58th Ave
FACILITY PHONE
(604) 856-3278
CITY
Abbotsford
POSTAL CODE
V4X 2G1
MANAGER
Keri Thomson

INSPECTION DATE
July 04, 2019
ADDITIONAL INSP. DATE (multi-day)
July 25, 2019
ADDITIONAL INSP. DATE (multi-day)
July 25, 2019
TIME SPENT (HRS.)
5.5
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
10:30 AM
DEPARTURE
12:00 PM
ARRIVAL
02:00 PM
DEPARTURE
03:00 PM
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

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/long-term-care-licensing/resources-for-long-term-care-licensees#.XTjld_lKiUl 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
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: In one PIC's washroom, moisture due to lack of proper ventilation, has resulted in rusty grab bars beside the toilet. There was a hole in the wall beside the sink. Also of concern is the sloped surface of the flooring in the bathing area which has resulted in water leaking into the adjacent room and staff are using towels to keep the water inside the bathing area.
Damage was incurred to the kitchen cabinet above the toaster due to a recent fire. Staff were told to put tape over the splintered wood. Please ensure that the cabinet is fixed.
Corrective Action(s): Please ensure that all furniture and equipment for use by persons in care re in a good state of repair.
Date to be Corrected: August 15, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation (CORRECTED DURING INSPECTION): In a washroom shared by two PICs, it was noted that there was an electric toothbrush and multiple regular toothbrushes on the counter. Staff stated that all 4 toothbrushes belonged to one PIC. These items should be stored in a labelled bin. The toilet brush was noted to be in the cupboard in close proximity to the PICs’ clean towels. Please ensure that these items are kept separate to avoid cross-contamination.
In the gazebo in the backyard area, it was noted that rakes and shovels were kept unlocked. Given the previous incidents of aggressive behaviour at the home, please ensure these items are not accessible to PICs. Other items stored in the backyard such as the BBQs owned by the maintenance crew were noted to be unclean and with grease residue. In addition, light fixtures were noted to have bug residue. Both the bbqs and the light fixtures can pose a fire hazard.
Corrective Action(s): Corrected during inspection
Date to be Corrected: July 25, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): Extra supplies of medications were noted to be stored in a closest with other items. Meds need to be stored separately. It was also noted that a Tylenol bottle belonging to staff was also stored in this closet.
Corrective Action(s): Corrected during inspection
Date to be Corrected: July 25, 2019

POLICIES AND PROCEDURES: 33390 - RCR s.85(2)(g) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (g) monitoring of the nutrition of a person in care.
Observation: A review of policies and procedures on Sharepoint was done. A policy specific to the nutrition monitoring of PICs could not be located by facilty staff or licensing.
Corrective Action(s): Please ensure there is a policy to guide staff with respect to the nutrition monitoring of PICs.
Date to be Corrected: August 15, 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: Fridge temperatures were noted to be above 4 degrees C. Please note all food should be stored between 0-4 degrees.
The storage area of food was inspected. Bags of flour and sugar were noted to be kept in their original bags. Please ensure that food items are stored in sealed containers to protect against ants and/or other contamination.
In another room of the facility, other foods such as potatoes were found to be stored with non-food items.
Corrective Action(s): Corrected during inspection
Date to be Corrected: July 25, 2019

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation (CORRECTED DURING INSPECTION): A summer menu dated 2010 was posted on the fridge. The staff explained that a new menu is being approved. The menu currently being does not document 2 food groups from the CFG for certain snacks. Staff stated that this has been incorporated into the new menu and they are serving two food groups. Please ensure that this is documented in the current menu.
Corrective Action(s): Corrected during inspection
Date to be Corrected: July 25, 2019


Comments

In the room adjacent to one PIC’s room there are multiple cords strewn about connected to the equipment utilized by the PIC. The facility may want to monitor to ensure better arrangement of furniture and cords is implemented to minimize it being a tripping hazard.

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
Aug 15, 2019

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