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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

VDAN-AG9V9B

FACILITY NAME Alice Lake Place Group Home		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1003558
FACILITY ADDRESS 2724 Alice Lake Pl			FACILITY PHONE (604) 941-4918
CITY Coquitlam	POSTAL CODE V3C 5W8		MANAGER Jenny Desjardins

INSPECTION DATE December 02, 2016	ADDITIONAL INSP. DATE (multi-day) December 07, 2016		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 5
ARRIVAL 12:00 PM	DEPARTURE 05:00 PM	ARRIVAL 10:30 AM	DEPARTURE 01:00 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED 4

Introduction

This is an unscheduled routine inspection to assess the facility compliance with the Community Care and Assisted Living Act (CCALA), Resident Bill of Rights (RBR), the relevant Director of Licensing Standards of Practice (DOLSP) and Resident Care Regulations (RCR). 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
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records and Record Keeping

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 fo:
additional resources and
links to the Legislation (CCALA & RCR)

If you have any questions regarding this report, feel free to contact me at:
tel. 604-949-7710
valerie.dairon@fraserhealth.ca

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: There is a new bistro style dining table. This table was observed to wobble when touched. The manager states that there are 2 screws missing from its assembly, but that the table is safe and the retailer will provide the screws. The bottom drawer of a resident's blue dresser was observed to be broken and would not stay appropriately on its runners.
Corrective Action(s): Please ensure that all table surfaces are stable, and furnishings are well maintained.
Date to be Corrected: Dec. 15, 2016

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: Sunscreen was observed in the main bathroom drawer.
Corrective Action(s): Please ensure that all medications are appropriately stored.
Date to be Corrected: Dec. 15, 2016

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: Prn medications were not appropriately signed for results of the drug administration.
Corrective Action(s): Please ensure that all PRN medications are signed with results of the medication documented
Date to be Corrected: Dec. 15, 2016

POLICIES AND PROCEDURES: 33320 - RCR s.85(2)(b) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (b) the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Observation: Of 2 staff files reviewed, there was no observation of staff orientation to the CCALA or the RCR either in the orientation checklist or other areas of the staff file.
Corrective Action(s): Please ensure that the Orientation Policy contains reference to the orientation to the Legislation and that there is evidence that this occurs.
Date to be Corrected: Dec. 19, 2016

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: There were some pieces of food in fridge and freezer that were not labelled,
Corrective Action(s): Please ensure that all food is appropriately labelled.
Date to be Corrected: Dec. 15, 2016

Comments

This facility is very attractively decorated and each room reflects the personal interests of the residents. The house appears well organized and clean.
The fridge freezer temperature was found to be only -13 degrees centigrade. The manager states the fridge is quite old. The continuing log of freezer temperatures, taken at night, shows most temps to be in required range. It was speculated that the fridge may take longer to reach ideal temperature after the door is opened because of its age.
The food cupboards are locked. This represents a restriction of the freedom of residents to access food at will. The purpose of locking the cupboards is to limit access to one resident who is observed to have a doctor's note supporting this practice. The manager states that the resident's parent agrees and is expected to sign consent for the restriction this afternoon. The manager also states that for the other residents, they only need to request a snack and staff will provide it. This appears to meet the medical needs of one resident and the intent of the legislation for the remaining residents.
The menu was reviewed and snacks were found to be identified as one OR the other. This wording implies that only one snack would be offered. The drinks that were to be offered with the snacks did not include milk, but water was included twice, this was a typo error by the manager and will be corrected.
The meals were reviewed, and it was difficult to determine if the residents would receive a full food group of each food item as there were a lot of casserole style dishes offered. The problem was reviewed with the manager. It was also observed that jello and pudding was offered in the meals and snacks. As neither of these foods is considered to be in a food group, the manager will consider their use as an additive to a meal or snack and not as one of the food groups.
The policy and procedures were reviewed. These appeared to be outdated but other documentation was found that identified revisions of several of the mandatory policies (RCR 85(2)(a-l)) The HR director was present at this inspection and confirmed that she was part of the committee that reviews all policies every year, and that only the policies requiring revision are documented. It is suggested that there be a way of documenting confirmation the review of the policies has occurred each year.
The financial documentation of one of the residents was reviewed. There was one dollar missing. The staff confirmed that in cases of small amounts of missing funds, the total is made up. Receipts for financial activities were present.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Dec 19, 2016

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