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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CCHSN4
FACILITY NAME
Evergreen House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
LBAA-8VPVD3
FACILITY ADDRESS
638 Kemsley Ave		FACILITY PHONE
(604) 931-0974
CITY
Coquitlam		POSTAL CODE
V3J 3Z3		MANAGER
Kate Mireku
INSPECTION DATE
March 14, 2022		ADDITIONAL INSP. DATE (multi-day)
March 15, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
09:00 AM		DEPARTURE
11:00 AM		ARRIVAL
01:00 PM		DEPARTURE
02:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
4
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/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: 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: The baseboards located at the front entrance and throughout the main hallways had more than several sections of chipped paint along the entire baseboard.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 14, 2022
Comments

I would like to thank the team at Evergreen House for their time and assistance in the completing this inspection. Due to infection control practices in place related to COVID-19 prevention, this report was written off-site and is therefore unsigned. The report was reviewed with facility leadership and an email copy was provided. If there are further questions related to this routine inspection, please contact your Licensing Officer.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Apr 14, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.