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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-AXVPU2
FACILITY NAME
123rd Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081391
FACILITY ADDRESS
20878 123rd Ave
FACILITY PHONE
(
604
)
463-5484
CITY
Maple Ridge
POSTAL CODE
V2X 4B2
MANAGER
Peter Scheltgen
INSPECTION DATE
April 11, 2018
ADDITIONAL INSP. DATE (multi-day)
April 16, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
02:00 PM
DEPARTURE
03:00 PM
ARRIVAL
10:00 AM
DEPARTURE
12:00 PM
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 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 604-949-7714 or by email at nicholas.birch@fraserhealth.ca
Contraventions
Previous Inspection -
Contraventions observed on FIR #NBIH-AMPR92 have been corrected except for those noted on supplementary pages.
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 the inspection the following was noted:
- The floors in both bathrooms are cracked an peeling in multiple areas. This is a repeat contravention from the 2017 routine inspection. The manager stated that BC Housing has come to the facility to review the repair/replacement of the floors but no time-line has been provided yet.
- Multiple door kick plates throughout the house are cracked and peeling off the door. These are sharp and pose a health and safety risk to the PIC's.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 31 2018
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: As per the agency policy, all staff will receive an annual evaluation. 1 staff member at the facility has not received an annual evaluation since 2016.
Corrective Action(s): Please ensure that all staff receive an annual evaluation as per agency policy.
Date to be Corrected: May 15 2018
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): During the inspection one PRN medication was found to be expired (Oct. 2017)
Corrective Action(s): Please ensure that all expired medications are returned to the pharmacy.
Date to be Corrected: April 16 2018
Comments
Action Required by Licensee/Manager
Action Required by Licensing Staff
No action required
No action
required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.