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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-C5YSY4

FACILITY NAME
58th Avenue Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782286
FACILITY ADDRESS
29172 58th Ave
FACILITY PHONE
(604) 856-3278
CITY
Abbotsford
POSTAL CODE
V4X 2G1
MANAGER
Keri Thomson

INSPECTION DATE
August 17, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

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

Care systems reviewed during inspections and investigations include the following: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & 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).

Contraventions
Previous Inspection -
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: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: -In one bathroom, it was observed that the floor around the toilet appeared yellow, and/or discolored. The staff bathroom and laundry room have thick dust collected on air vents on the ceiling.

Outside in the secondary back yard, the following was observed:
-The gate, and a portion of the fenced area that secured the yard, and made it inaccessible to persons in care, has a large section of fence missing, as well as a missing gate. Of concern is a shed, barn/ storage, and a camper that would usually be inaccessible to persons in care (as follows)...
-a camper is being stored, the camper is mounted on wooden work bench/stand. Of concern is the camper has been left at the site, and is no longer useable, and the wood stands supporting the camper is becoming weathered and worn, with the potential of collapse or falling over at some point.
-Next to the camper is an older shed, that was previously used as a chicken coop, the shed is no longer in use but still contains what appears to be chicken nesting materials, and chicken waste, there is also a wasp nest in the shed, the shed is not locked, and could potentially be accessed by persons in care.
-There is a large barn on the property being used to store "donations", some items in the barn have been set aside for disposal, but a plan for disposal has not yet been determined.
-There is a large pile of yard waste between the secondary yard, and the driveway which appears to have been collecting for an extended period of time.
-There is a shed (tractor type shed) that has remnants of plywood and what appeared to be drywall out in the elements, and not for use in the care facility, and potentially accessible to persons in care.
Corrective Action(s): Ensure all rooms and common areas maintained in a safe and clean condition. Please submit a plan to licensing addressing the above items.
Date to be Corrected: September 6, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: In the freezer it was observed that a number of tubes of what appeared to be ground beef, had been removed from the original packaging, and was not labeled with the date. There was also another food item in the chest freezer, removed from its original packaging, and did not have a date/ expiry date labelled on the item.
Corrective Action(s): Ensure all food is safely prepared, stored, served and handled.
Date to be Corrected: September 6, 2021


Comments

Staff files are kept at head office, a check list was reviewed on site to confirm that staff are up to date with qualifications, training and performance reviews. LO will schedule a time to review complete staff files at head office in the next couple of months.

This inspection report was reviewed and delivered via E-mail due to Covid-19 protocols.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Sep 06, 2021

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