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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

VDAN-AFHQWB

FACILITY NAME Gray House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 3203598
FACILITY ADDRESS 6957 Gray Ave			FACILITY PHONE (604) 436-3970
CITY Burnaby	POSTAL CODE V5J 3Y9		MANAGER Christen Hansen

INSPECTION DATE November 08, 2016	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 09:00 AM	DEPARTURE 01:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED 4

Introduction

This is an announced annual Routine Inspection to determine compliance with the Community Care and Assisted Living Act (CCALA), the Residential Bill of Rights (RBR) and the Residential Care Regulations (RCR). The following systems were audited: -Licensing -Physical Facility -Staffing -Policies and Procedures -Care and Supervision -Hygiene and Communicable Disease -Medication -Nutrition and Food Services -Program -Records and Reporting

Contraventions

Previous Inspection - Contraventions observed on FIR #VDAN-A58UAN 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: 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: A generic antibiotic ointment and sunscreen were observed in PIC rooms Corrective Action(s): Please provide a plan that will ensure that all medications are ordered by a physician, packaged by a pharmacist and stored in a secure place. This is a repeat observation from previous inspection. Date to be Corrected: November 22, 2016 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: Personal care products were observed that were not labelled, a nail clipper and shampoos, body wash. Corrective Action(s): Please ensure that all personal products are labelled or stored in separate spaces for use by one PIC only. Date to be Corrected: Nov. 22, 2016

Comments

This is a very pleasant facility to visit. The front entrance and living room are very attractively decorated and the manager states the residents express appreciation for environmental details. Each of the clients' rooms are nicely fitted with expressions of their interests and personal touches. Each PIC introduced themselves to the writer and appeared happy and confident in their environment. Observed interactions with staff and residents appeared congenial and upbeat. The Nutrition Monitoring policy was not reviewed again this year. The manager states that the contravention for last year (33390, RCR 85(2)(g)) was forwarded to the head office but there has been no adjustment to the policy returned as yet. The nutrition monitoring systems in the house were reviewed. Audits for the menus and PIC's are being done, weights are done and assessed monthly. The meals audited appeared to contain 3 food groups and snacks contain 2 food groups. The admission weight and height of the one PIC who was audited was not apparent. The manager stated that it could be located in a stored file. The admission weight and height, if not located, can be substituted with the oldest know values and identified as such. Please inform licensing of the inclusion of admission height and weight information and its continued retention in the current care plan for each resident when responding to this inspection. A spreadsheet for required documentation for staff was reviewed. Each of the required components was either up to date or were in process and being supervised for completion by the manager. I would like to thank the staff, residents and manager for their assistance with 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 Nov 22, 2016

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