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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BLSRQD

FACILITY NAME
Fleet Street Group Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
LBAA-8CFSTG
FACILITY ADDRESS
2994 Fleet St
FACILITY PHONE
(604) 944-0408
CITY
Coquitlam
POSTAL CODE
V3C 3R8
MANAGER
Dorine Lata

INSPECTION DATE
February 13, 2020
ADDITIONAL INSP. DATE (multi-day)
February 14, 2020
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
02:00 PM
DEPARTURE
04:00 PM
ARRIVAL
01:30 PM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 (DOLSOP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · 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/residentialcare for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: 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: Inspection of 1 common bathroom upstairs found that bathtub had taped rusted area making cleaning and sanitization difficult..
Corrective Action(s): Please ensure bathtub is maintained in safe and clean condition.
Date to be Corrected: March 31st, 2020

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: The kitchen baseboards were missing at the entrance and there are some areas with scruffs in the wall.
Corrective Action(s): Please ensure that all common areas are maintained in good state of repair. The facility is in the process of doing minor maintenance as per the manager.
Date to be Corrected: March 31st, 2020


Comments

The Licensing Officer (LO) would like to thank the Manager for her time and assistance in completing this routine inspection. LO has provided the Licensee detailed instructions to set up account for online reporting of Reportable Incidents from January 1st, 2020. The new manager has now be updated on Healthspace, sample Health and safety plan has been given to the manager and manager made aware of Schedule D of the Reportable Incidents.
This report was reviewed and discussed with manager. A copy of this report was left at the facility.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Mar 31, 2020

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