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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-C7SN4A

FACILITY NAME
Eleanor House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782340
FACILITY ADDRESS
2052 Eleanor Ave
FACILITY PHONE
(604) 859-2907
CITY
Abbotsford
POSTAL CODE
V2S 4L6
MANAGER
Kristie Osen

INSPECTION DATE
October 13, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

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, Policies and Procedures, 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 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: 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: One vacant bedroom has a hole in the drywall, and a missing piece of rubber baseboard trim, this room will be used to accommodate another person in care.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair. Staff explained that the home, and the described bedroom are being repaired in anticipation of a new admission.
Date to be Corrected: November 4, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: In one bathroom, there was a shaving razor and personal hygiene products left out on the counter, as well as a toilet brush stored in the closet near a shelf with clean towels. Of concern is the safety risk of the unattended razor, and the potential for cross contamination or splashing on to clean supplies.
Corrective Action(s): Ensure secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected: November 4, 2021

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: The site was unable to provide evidence of any recent or annual examination by a dental health care professional.
Corrective Action(s): Ensure records are kept encouraging annual examination by a dental health professional.
Date to be Corrected:

RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Upon review of one person in care's record, there was an incident that occurred, that meets the definition of reportable, however the incident was not reported to licensing, as per the facilities reportable incident policy. It was also not documented on an internal incident report.
Corrective Action(s): Ensure if a person in care is involved in a reportable incident, that the medical health officer is notified in the form and manner required. Please submit this incident as a reportable incident, by November 4, 2021.
Date to be Corrected: November 4, 2021

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: 2 of 2 person in care files reviewed were missing weights for 2 of the 9 months reviewed. There was no reason documented as to why the facility was unable to obtain the monthly weights.
Corrective Action(s): Ensure each person in care is weighed at least once each month.
Date to be Corrected:


Comments

A staff file review at the H.O.M.E society head office was conducted in September 2021.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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