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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B62T7B

FACILITY NAME
Dania Home
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
TBIU-9S9PWM
FACILITY ADDRESS
4175 Norland Ave
FACILITY PHONE
(604) 299-2414
CITY
Burnaby
POSTAL CODE
V4G 3Z6
MANAGER
Chantal Morris

INSPECTION DATE
October 30, 2018
ADDITIONAL INSP. DATE (multi-day)
November 02, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10
ARRIVAL
09:00 AM
DEPARTURE
05:00 PM
ARRIVAL
11:45 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604 918-7526, or valerie.dairon@fraserhealth.ca

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-APLKSW have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Four staff files were reviewed. Three appeared to be deficient in staff performance appraisals. The Care Coordinator stated that, as the facility has changed to a new care contractor within the last 6 months, it was necessary to become familiar with the staff before providing performance assessments. The Policy for performance appraisal (PA) was reviewed, and indicated that PA's are to be conducted before the end of 3 month probationary period. There are approximately 115-125 staff members. The Care coordinator demonstrated that approximately 75% of the PA's had been completed or initiated at this point.
Corrective Action(s): Please provide a plan for completion of the remaining PA's and include the plan proposed for the future to ensure that the regulation continues to be met.
Date to be Corrected: Nov. 21, 2018

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: The shower/tub room on the first floor was reviewed and an unlabelled razor was found wrapped in paper towel in a basket with the hairdryer. The RCA who was in the room removed it immediately and disposed of it.
Corrective Action(s): Please provide a plan that will ensure that there is no opportunity for personal care items such as razors to be used between persons in care.
Date to be Corrected: Nov.21,2018


Comments

The Activity coordinator has recently joined the staff. A review of the licensing regulations for activity programming took place as well as a review of the screening requirements for volunteers.
The resident satisfaction audits were reviewed for October. The complaints from previous routine inspection about a lot of fish and chicken were not reflected in these audits. The Food Service Manager discussed strategies for providing special requests for residents.
The Policy and Procedures were confirmed to have been reviewed in 2018.
Fire drills are conducted monthly on all three shifts. The staff receive inservice on emergency preparedness and equipment use.
This facility is clean, tidy and well organized. All staff were ready to help with any licensing questions. Resident activities, both group and individual, were observed to be engaging many residents. There are systems in place to ensure everyone is involved at the level of activity of their choosing.

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
Nov 21, 2018

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