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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B5UTVU
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
Anna Gao
INSPECTION DATE
October 24, 2018		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
01:30 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 604 918-7526 or valerie.dairon@fraserhealth.ca
Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-APDV54 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
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: The radio for the emergency kit was missing. The food was within the expiry date, but did not appear sufficient to support 6 people for 3 days in an emergency.
Corrective Action(s): Please ensure that the items identified on the emergency preparation checklist are available in the emergency supplies in the event of an emergency.
Date to be Corrected: Nov. 15, 2018

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: There was not an active plan to ensure that each PIC would have an annual dental exam.
Corrective Action(s): Please provide a plan to ensure that each PIC has an opportunity for professional dental exam at least annually.
Date to be Corrected: Nov. 15, 2018.

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: One week's menu, week #1, was audited and one meal and one snack did not have the required food groups. The menu did not give direction to staff to provide beverage in an alternate food group.
Corrective Action(s): Please provide a plan that will ensure that all meals have 3 food groups and all snacks have 2 food groups represented.
Date to be Corrected: Nov. 15, 2018

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: The menu substitution list was observed to have entries from the 21 and 23 of October 2018. The next most recent entry was recorded in July of 2018.
Corrective Action(s): Please ensure that there is a record of meal substitutions and the record is retained for inspection.
Date to be Corrected: Nov 15, 2018
Comments

In the previous inspection there was concern expressed about the plan for evacuating the downstairs resident who is wheelchair bound from the downstairs bedroom. The path that would need to be taken was either over a step in the patio or over thick lawn. This may prove difficult for a solitary house staff on night shift who must remove 3 other residents as well. This is a repeat concern.
Please provide a plan to address this issue.
This house is clean and well organized. The House Leader and the House Manager have been in place for approximately 7 weeks. They have been observed to interact in a friendly manner with the residents who in turn respond in a positive friendly manner.
I want to thank the House Leader and the Manager for their assistance with 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
Nov 15, 2018
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Click here for a description of each "Category" of violation displayed.