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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KPRK-C7XLTB

FACILITY NAME
Davison
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081235
FACILITY ADDRESS
19425 Davison Rd
FACILITY PHONE
(604) 465-8545
CITY
Pitt Meadows
POSTAL CODE
V3Y 1A7
MANAGER
Donna Vandekerkhove

INSPECTION DATE
October 05, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.5
ARRIVAL
09:00 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
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 Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DLSP).
The following areas were reviewed:

- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Contraventions
Previous Inspection - Contraventions observed on FIR #NBIH-BKU2KZ 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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Damage to the walls was noted in the kitchen and the back common room in the form of scrapes, dents, and missing paint. LO observed one living room chair to have vinyl material worn off on greater than 50% of the seating area.
Corrective Action(s): Please ensure furnishings are maintained in a good stated of repair.
Date to be Corrected: November 30, 2021

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: A 3 meter to 6 meter backyard fence was observed to be leaning on a 50 to 70 degree angle and could possibly fall down. This fence was in a poor state of repair and needed to be replaced. The facility manager stated this fence did not present an immediate risk to PICs, as they did not access this area of the backyard.
Corrective Action(s): Please ensure the backyard fence is maintained in a good state of repair.
Date to be Corrected: November 30, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Licensing noted there to be a raised fireplace hearth with exposed corners, which was accessible to persons in care (PIC). All 3 PICs living in the home had issues with mobility where a risk for fall was possible. The brick corners angled into a point and was a potential hazard to a PIC that may fall toward it.
Corrective Action(s): Please ensure the risk to the PICs from the corners of the fireplace is addressed immediately.
Date to be Corrected: October 22, 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: Licensing noted the cleaning supplies were accessible to persons in care in the open laundry room, on the kitchen pass through window, and in the washroom.
Corrective Action(s): Please ensure the safe and secure storage of cleaning agents.
Date to be Corrected: October 31, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Licensing noted the open laundry area to be without a slip resistant floor surface.
Corrective Action(s): Please ensure the laundry area has a slip resistant floor surface.
Date to be Corrected: October 31, 2021

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: In reviewing the menu Licensing noted snacks did not include two food groups in greater than 8 snacks listed.
Corrective Action(s): Please ensure each day, at least 2 nutritious snacks, each containing at least 2 food groups.
Date to be Corrected: November 15, 2021


Comments

Licensing observed a half door with an external lock at the entry of a room. The facility manager explained that persons in care were not able to open this door when the lock was engaged. This restraint had been used in the past as part of a person in care (PIC)'s behavioural invention plan. This plan was no longer in use and was documented as on hold in the PIC A's current Care Plan. Licensing discussed with the facility manager that, as the PIC was unable to unlock the door when the lock was engaged, it was a potential restraint. The facility manager stated that the door handle would be changed so it no longer could be used as a potential restraint.

Licensing explained that section 9(2) of the Community Care and Assisted Living Act requires that the Licensee produce records for review when requested by a Licensing Officer. Licensing generally reviews minor incident reports during a routine inspection and these records should be made available for review.

Licensing was not provided with evidence regarding staff training for the preparation and delivery of textured diets. The Manager reported informing staff how to prepare textured foods but confirmation of the Managers training was not available. A swallowing assessment by a Dietician occurred while Licensing was onsite.

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection.

Please provide a response to Licensing by October 25, 2021 as to how the identified items in this report will be addressed.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
(Please note: this inspection report was written off-site and later reviewed and forwarded to the Licensee. Therefore no signature was obtained.)

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
Oct 25, 2021

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