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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-AW8TQ9

FACILITY NAME
Czorny Alzheimer Centre
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962LCR
FACILITY ADDRESS
16850 66 Ave
FACILITY PHONE
(604) 575-6701
CITY
Surrey
POSTAL CODE
V3S 5M1
MANAGER
Louise Brown

INSPECTION DATE
February 22, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
10:30 AM
DEPARTURE
02:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
72

Introduction

An unscheduled routine inspection was completed with the Manager to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DLSP). 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 reporting

As part of this 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.

Please visit the Community Care Facilities Licensing (CCFL) website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:

* Additional resources, and

* Links to the legislation (CCALA and RCR)

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: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: A random review of five care plans indicated that for a person in care their recreational care plan was not in-place. The specifics of which care plan was not in-place was provided to the Manager.
Corrective Action(s): Please ensure all persons in care have a recreational care plan in-place.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: A random review of five care plans indicated for one care plan the date was not noted. The specifics of which care plan needed a date was provided to the Manager who will follow-up.
Corrective Action(s): Please ensure all care plans are reviewed and if necessary modified once a year.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: A random review of the weight records indicated for a cottage that the January 2018 weights were not noted for some persons in care. The Manager stated they will follow-up on this.
Corrective Action(s): Please ensure monthly weights for all persons in care are monitored and documented. If for whatever reason the person in care(s) can't be weighed, for example, person in care refuses, weight scale is not functioning, etc, then this should be documented accordingly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.


Comments

Nutrition audits:

The Dietitian was not on-site during the inspection. The Manager will check with the Dietitian as to the nutrition audits that have been completed such as a menu audit and then a response provided to the writer. The writer will also e-mail the audits and more manual to the Manager which has sample audits noted in it.

Medications:

Overall it appears the medication administration records and PRN (as needed) medications are charted thoroughly including the result/effectiveness for the PRNs, however there appears to be some results/effects not noted. The Manager is aware of this and will reinforce with all the care staff that the result/effectiveness for the PRN medications needs to be charted.

Summary:

Overall it appears Czorny Alzheimer Centre has thorough systems in-place to meet the intent of the Residential Care Regulation. The building itself is well maintained and the interior beautifully presented with the decor and homelike feel. Thank you once again for your time to complete today's inspection and if there are any questions, please feel free to contact your Licensing Officer.

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
Mar 02, 2018

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