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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-B6HRUB

FACILITY NAME
Como Lake House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081662
FACILITY ADDRESS
1433 Como Lake Ave
FACILITY PHONE
(604) 931-3272
CITY
Coquitlam
POSTAL CODE
V3J 3P5
MANAGER
Katherine Tiongson

INSPECTION DATE
November 14, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
09:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: 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: During inspection it was noted that
*1 missing light cover in the hallway between the kitchen and bathroom
*Front door paint was peeling off and wood showing through
*Bathroom shelf is water damaged and paint peeling
*Bathroom wall has some holes and paint chipping
*Bathroom screen in the window has dust and dirt on it
*Under the sink in the laundry room the shelf is broken
*In 1 PIC's room the blinds were broke and falling off
Corrective Action(s): Ensure all rooms and common areas are maintained in a state of good repair
Date to be Corrected: Dec 12, 2018

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: It was noted that there were 8 missing PRN responses on 2 PIC's MARs
Corrective Action(s): Ensure all staff comply with the policies and procedures of the MSAC
Date to be Corrected: Nov 28, 2018

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Upon review of 2 PIC's files it was noted that 1 PIC was missing the TB immunization forms
Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Provinces immunization and TB control program
Date to be Corrected: Nov 28 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: Upon inspection of the bathrooms it was noted that the commodes for each person were unlabeled with PIC's names
Corrective Action(s): Ensure personal hygiene items are labeled with the PIC's names
Date to be Corrected: Corrected During Inspection

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: During review of the emergency supplies it was noted that the fruit bars were expired
Corrective Action(s): Ensure all stored food is not expired
Date to be Corrected: Corrected During Inspection


Comments

The majority of food in the home was labeled appropriately with dates, a few items in containers need labels stating what the item in the container is.

Thank you to the Management and staff for their support and participation during the inspection

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 28, 2018

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