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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CH5SKF

FACILITY NAME
Innervisions Recovery Society Hannah House
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
ABII-6FZP9K
FACILITY ADDRESS
11982 Laity St
FACILITY PHONE
(604) 466-4215
CITY
Maple Ridge
POSTAL CODE
V2X 5A6
MANAGER
Joanna Schofield

INSPECTION DATE
August 09, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
10:20 AM
DEPARTURE
01:15 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 & 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 https://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: 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: Two black leather couches were observed to have multiple rips on the seating exposing the inner material located in Building 1. The fire alarm located in a PIC's bedroom was detached from the ceiling and was observed to be placed on top of the PIC's dresser.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected: September 9, 2022

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 (CORRECTED DURING INSPECTION): Disinfectants and chemicals were stored under the sink located in the bedroom making it accessible for PIC.
Corrective Action(s): Ensure that cleaning agents, chemical products and other hazardous materials are safe and securely stored.
Date to be Corrected: September 9, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A container of butter and jam were found placed inside a cabinet covered but without any dates or labels. A container of sugar was found on the counter uncovered and without any dates or labels.
Corrective Action(s): Ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: September 9, 2022


Comments

I would like to thank the team at Innervisions Recovery Society Hannah House for their time and assistance in the completing this inspection. Please submit a written response by September 9, 2022 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements. If you have any questions related to this report please feel free to contact me. Due to infection control practices in place related to COVID-19 prevention, this report was written off-site and is therefore unsigned. The report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Sep 09, 2022

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