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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBOI-BDGU32

FACILITY NAME
Forglen 5452
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
NGIL-7PBVL2
FACILITY ADDRESS
5452 Forglen Dr
FACILITY PHONE
(604) 435-4110
CITY
Burnaby
POSTAL CODE
V5H 3K7
MANAGER
Elmo Jackson

INSPECTION DATE
June 11, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:00 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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
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: The LO noted on inspection that in one of the shared bathrooms bar soap is being used, and there are hand towels.
Corrective Action(s): To prevent cross contamination please ensure PIC's have hygiene items that are not shared.
Date to be Corrected: August 1, 2019

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: It was noted that on review of the menu that approx 5/7 days of each week only include one food group for snack. This is a repeat contravention from the 2018 routine inspection.
Corrective Action(s): Ensure that at least 2 nutritious snacks are served that contain 2 food groups.
Date to be Corrected: August 15, 2019

NUTRITION AND FOOD SERVICES: 37050 - RCR s.62(2)(c)(i) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (i) the nutrition plan of each person in care and the nutrition needs, age, gender and level of activity of the persons in care.
Observation: Review of the menu audit available for both the summer and winter menu found that the audit identified that the menu did not meet the canada food guide requirements, yet there was no update to the menu. This is a repeat contravention from the 2018 routine inspection.
Corrective Action(s): Ensure that the menu provides the requirements for the needs of the PIC's
Date to be Corrected: August 15, 2019


Comments

The temperature of the water could not be checked as the LO's thermometer was not working. The manager confirms that a maintenance person turned down the hot water temperature since the last inspection.

Thank you to the team at Forglen for their assistance with the inspection today.

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 16, 2019

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