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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-CP5UNC
FACILITY NAME
Dufferin Care Centre		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTGK
FACILITY ADDRESS
1131 Dufferin St		FACILITY PHONE
(604) 552-1166
CITY
Coquitlam		POSTAL CODE
V3B 7X5		MANAGER
Simi Sharma
INSPECTION DATE
February 17, 2023		ADDITIONAL INSP. DATE (multi-day)
February 16, 2023		ADDITIONAL INSP. DATE (multi-day)
January 31, 2023		TIME SPENT (HRS.)
8
ARRIVAL
09:30 AM		DEPARTURE
02:30 PM		ARRIVAL
02:30 PM		DEPARTURE
04:30 PM		ARRIVAL
01:15 PM		DEPARTURE
02:15 PM
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 Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSOP). 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
Programming
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 :http://www.gov.bc.ca/residentialcarefacility
· Additional resources, and
· Links to the Legislation (CCALA and 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
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: The medication count requiring two staff to verify and sign for it in the medication room was not completed appropriately twice in November and once in December in 2022. Only one staff had signed for the medications in the register.
Corrective Action(s): Please ensure that all staff comply with the policies and procedures of MSAC.
Date to be Corrected: March 3, 2023

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: The admission checklist has not been completed appropriately by staff person for 2/7 PICs. There were blank spaces left for many slots depicting pertinent task that must be completed within 3 days post admission as per the admission policy.
Corrective Action(s): Please ensure that policies are implemented appropriately by employees.
Date to be Corrected: March 3, 2023

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: 1/7 PIC charts did not have evidence of any encouragement provided to the PIC to be examined by a dental care professional at least once last year.
Corrective Action(s): Please ensure that PICs are encouraged at least once every year to be examined by a dental health professional.
Date to be Corrected: March 3, 2023
Comments

Licensing would like to thank the site's leadership for their time and assistance in completing this routine inspection.

It was observed that several walls in the hallways had chipped corners where metal beading was exposed and scruff and dents marks are present on doors and at random areas of the hallways. The leadership is working on getting these areas repaired. The need for a health and safety plan for painting has been discussed by the LO. The documentary evidence of emergency plan and evacuation was looked into and discussed during this inspection. The leadership has been asked to provide specifics and further details in the plan in terms of the locations; including addressing all the areas of the care needs for the PICs.

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
Mar 03, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.