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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-APDV54
FACILITY NAME
Holly		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203584
FACILITY ADDRESS
7473 Holly St		FACILITY PHONE
(604) 526-5216
CITY
Burnaby		POSTAL CODE
V5E 2C3		MANAGER
Michael Wesko
INSPECTION DATE
July 18, 2017		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
12:45 PM		DEPARTURE
05:00 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 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 7710
Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-AD7M7W 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: 31530 - RCR s.28(2) - A licensee must ensure that the window of each bedroom can be opened easily for ventilation, unless (a) it would be unsuitable to the health, safety or dignity of the occupant, or (b) the community care facility is equipped with an air conditioning system or mechanical ventilating system.
Observation: The window frame in the downstairs bathroom was observed to very soft, easily displaced around the window opening lever. The right side window of the upstairs front bedroom is blocked by a piece of plywood for an air conditioner. The window sills appear dirty and the paint has flaked off. The person requiring the air conditioning has moved from the house.
Corrective Action(s): Please provide a plan that will ensure that all windows are in a safe and good state of repair and can open and close as they are intended.
Date to be Corrected: July 31, 2017

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: The substitution record has not be kept since Dec. 2016. This is a repeat contravention from last year.
Corrective Action(s): Please ensure that the substitution record is maintained as a means of monitoring the nutrition of the PIC's.
Date to be Corrected: July 31, 2017

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: A consent to call medical, nursing practitioner or ambulance was not observed in the Care Plan that was reviewed.
Corrective Action(s): Please sure that all PICs have completed a consent for medical care.
Date to be Corrected: July 31, 2017

RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: Weight records were observed for one PIC to be missing since March 2017
Corrective Action(s): Please ensure that weights are recorded monthly as part of nutritional monitoring.
Date to be Corrected: July 31, 2017
Comments

The Emergency exits were reviewed and were seen to be free of obstacles. The meeting space post evacuation as per the emergency plan is the bottom of the driveway. There is only one sleeping overnight person. The PIC living on the first floor needs to be evacuated per wheel chair. The bedroom exit door goes out to a concrete patio, but the patio has a step (7") high before the wheelchair can get to the level to get down the driveway. The manager expressed concern that a staff of small stature would have difficulty getting the wheelchair over the 7" rise in the concrete, and would also have a lot of difficulty pushing the wheelchair for approx. 20 yards over the grass around the step, particularly if the grass has been rained on for weeks.
Please provide a plan to ensure that evacuation of the house can be expedited and safety of staff is ensured. It is also noted that staff must re-enter the house to evacuate two other PICs. One of the upstairs PIC's is anticipated to have difficulty ambulating down the escape stairs.

The medication administration policy was reviewed. It was noted that there is one PIC who receives a PRN for pain at a vocational site. The direction in the policy does not provide guidance to facility/vacational staff for the management of the MAR that is completed at the vocational site. The facility staff need to know whether the PRNs have been administered and the pain has been managed.
Please provide a plan that allow the policy to direct staff in order to determine how medications (MAR sheet) are to be monitored for PIC in vocational/day program.

This facility has achieved an very much improved level of compliance. I would like to thank the staff and residents for their assistance in this 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
Jul 31, 2017
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.