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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-C6VLRL

FACILITY NAME
Oriole Lodge
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
0703865
FACILITY ADDRESS
32539 Oriole Cres
FACILITY PHONE
(604) 504-7549
CITY
Abbotsford
POSTAL CODE
V2T 4C7
MANAGER
Ryley Dales

INSPECTION DATE
September 14, 2021
ADDITIONAL INSP. DATE (multi-day)
September 16, 2021
ADDITIONAL INSP. DATE (multi-day)
September 20, 2021
TIME SPENT (HRS.)
6.5
ARRIVAL
10:30 AM
DEPARTURE
03:30 PM
ARRIVAL
10:45 AM
DEPARTURE
11:15 AM
ARRIVAL
01:00 PM
DEPARTURE
02:00 PM
INSPECTION TYPE
Routine
# OBSERVED IN CARE
9

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (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.

Care systems reviewed during inspections and investigations include the following:
Licensing
Physical Facility
Staffing
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & 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
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
LICENSING: 30160 - RCR s.11(1)(b) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (b) the most recent routine inspection record made under section 9 (1)(d) of the Act.
Observation: The most recent routine inspection is not posted, instead, there is a sign instructing persons in care to ask for a copy.
Corrective Action(s): Please ensure to post, in a prominent place, the most recent routine inspection record as required.
Date to be Corrected: September 24, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Licensee currently has an approved exemption for water temperature to be no higher than 53 degrees Celsius, however during the inspection it was observed that in two areas, the water temperature was 55.4 and 58.6 degrees Celsius respectively.
Corrective Action(s): Please ensure that as per the approved exemption request, the water temperature is not higher than 53 degrees Celsius as is checked daily to ensure compliance.
Date to be Corrected: Immediately.

STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: The Licensee was unable to provide evidence of a completed criminal record check for one staff
Corrective Action(s): Please ensure that all staff have a completed criminal record check as required.
Date to be Corrected: Immediately

STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: In a review of staff files, one staff file contained only one reference and a second staff had no references.
Corrective Action(s): Please ensure you have obtained character references for all staff.
Date to be Corrected: September 24, 2021

STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: The Licensee was unable to provide evidence of one staff's diplomas, certificates or other training and skills.
Corrective Action(s): Please ensure that you obtain staff diploma's certificates or other evidence of the person's training and skills.
Date to be Corrected: September 24, 2021

STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: One staff had no evidence of compliance with the Province's immunization and tuberculosis control program, and a seconds staff had no evidence of compliance with the Province's immunization control program.
Corrective Action(s): Please ensure you obtained evidence of compliance with the Province's immunization and tuberculosis control program for all staff.
Date to be Corrected: September 24, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: One fridge which was designated for client use contained items that were expired and an item that was not labeled so contents were unknown and expiration date was unknown. The current monitoring system in place is that staff are to check weekly and ensure that food in the fridge is properly stored and labled.
Corrective Action(s): Please ensure that items are disposed of prior to their expiration date and that items are labeled with their contents if removed from their original containers.
Date to be Corrected: September 24, 2021


Comments

On day 1 of the inspection LO Kimberly Bell was accompanied on this inspection by LO Student Debbie Lawless.
Day 2 of the inspection LO Kimberly Bell was in attendance.

Upon arrival at the facility, it was confirmed that the manager of record position was vacant as of the week prior, and a new manager would be starting on October 1, 2021. During this period with a manager, the Licensee will be available and the on-site nurse would assume the duties and responsibilities of the manager until the new manager is onboard.

Policies and Procedures were not reviewed in full during this inspection. A follow up inspection will occur with the on-coming manager in October 2021 to review the legislative requirements for Policies and Procedures

In discussion with the Licensee it was confirmed that the routine re-painting of the interior of the home will be occurring in December 2021 to January 2022 when less clients will be in care. A health and safety plan will be submitted to CCFL prior to the re-painting occurring.

It was discussed with the Licensee, that any staff person who is at the facility on a regular basis is required to meet the legislative requirements related to employee files.

It was confirmed that the previously approved exemption dated June 19, 2009 for RCR s.17 A Licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius, was not longer required. The facility will be in compliance with this regulation and will implement a system of monitoring going forward.

A written response to this report is not required at this time.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required

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