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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-BG6NCV

FACILITY NAME
Firth Residence
SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
DANN-A5XVZ3
FACILITY ADDRESS
Removed at operator's request
FACILITY PHONE
Removed at operator's request
CITY
Abbotsford
POSTAL CODE
Removed at operator's request
MANAGER
Removed at operator's request

INSPECTION DATE
September 17, 2019
ADDITIONAL INSP. DATE (multi-day)
September 19, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
09:30 AM
DEPARTURE
02:00 PM
ARRIVAL
11:00 AM
DEPARTURE
12:30 PM
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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report, please feel free to contact the geographic area Licensing Officer.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: A change of manager has taken place without notification to licensing within 30 days. New manager has been acting manager since June 2019.
Corrective Action(s): Ensure that if a manager resigns or expects to be absent for 30 consecutive days, the licensee must notify licensing or the change.
Date to be Corrected: Sept 30, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Some rooms were in need of repair, including: A ceiling tile in one bathroom was missing and appeared to be due to a leak (vacant room); and electrical outlet missing a face plate, making it a risk for injury; 1 bathroom fan was missing the cover leaving the fan exposed; 1 bathtub was missing the center knob on the water tap;
Corrective Action(s): Ensure rooms and common areas are maintained in a good state of repair.
Date to be Corrected: October 21, 2019

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: Rooms and/ or common area not in a safe and clean condition include: the laundry room had what appeared to be rodent droppings, as well as dirt/ debris on the floor, and spider webs around the ceiling; the air-conditioner unit in at least 1 room was covered in dust and in need of cleaning; in at least 5 rooms the box spring mattress did not have a cover over it, making it difficult to clean and keep in clean condition; 1 bathroom had rust on the shower head; and one person in care had open food in their room, which could potentially attract pests.
Corrective Action(s): Ensure rooms and common areas are maintained in safe and clean condition.
Date to be Corrected: October 21, 2019

POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Upon review of the facilities policy and procedure manual, the last annual review took place May, 2018.
Corrective Action(s): Ensure that policies and procedures are reviewed, and if necessary, revised at least once per year.
Date to be Corrected: October 21, 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: On review of the current menu it was noted that on at least 4 days snacks served contained only one food group.
Corrective Action(s): Ensure for each day, at least 2 nutritious snacks are served, with each snack containing at least 2 food groups as described in the Canada food guide.
Date to be Corrected: October 21, 2019

RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: On review of 3 care records, 1 person in care gave consent to be weighed but did not have their weight recorded on admission, they were weighed after the first month.
Corrective Action(s): Please ensure that weights for persons in care are recorded on admission.
Date to be Corrected:


Comments

-LO provided manager with a detailed package to get set up with online incident reporting for November 1, 2019
-LO provided manager with a structural change bulletin, as there has been some discussion about potentially renovating and expanding the kitchen. Please submit plans for structural change, and a health and safety plan well in advance of beginning any construction.
-LO and manger discussed review of protocol on weighing persons in care, as people in care can choose not to give consent to be weighed.
-LO and manager discussed adding a doorlock to the mechanical room, which can be accessed through the laundry room, as it should be inaccessible to persons in care.
-Recommendation to keep a staffing checklist on site for licensing to review, confirming that staff have obtained all of the requirements of RCR s.37, and the dates that each item is up for renewal, as complete staff files are kept at head office. It was determined at this time that staff files are up to date, as HR notifies staff individually when credentials need to be updated.. LO will review staff files at head office at a later date.
-Note: Firth residence cook will be attending the Nutrition workshop with the licensing dietician on September 26, 2019.

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
Oct 21, 2019

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