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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B8B2M2
FACILITY NAME
Kiwanis Care Centre		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
2501021
FACILITY ADDRESS
35 Clute St		FACILITY PHONE
(604) 525-6471
CITY
New Westminster		POSTAL CODE
V3L 1Z5		MANAGER
Lorrie Gerrard
INSPECTION DATE
January 10, 2019		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
01:30 PM		DEPARTURE
05:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
75
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 - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
CARE AND/OR SUPERVISION: 34700 - RCR s.81(3)(f)(i) - A care plan must include all of the following: (f) if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan (i) to prevent the person in care from leaving.
Observation: Assessment of the risk for newly admitted PIC leaving the facility without notification of an employee was not identified in the documentation for 4 files reviewed.
Corrective Action(s): Please ensure there is a plan to assess if there is risk of the PIC leaving the facility without notifying staff on admission.
Date to be Corrected: January 17, 2019
Comments

This facility is well organized and approaches resident care in a systematic way, making adjustments to the care model as the need arises.
Previous contraventions have been addressed and sustained over the past year.
Pharmacy support is being provided by a new supplier. There is a new EMAR system that has been reported to have improved the medication administration system for the PICs.
I would like to thank the staff and residents for their participation in this inspection.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Jan 17, 2019
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.