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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JFUR-CVGLNR

FACILITY NAME
Davison
SERVICE TYPES
104 Specialized Residential Care Home
FACILITY LICENSE #
1081235
FACILITY ADDRESS
19425 Davison Rd
FACILITY PHONE
(604) 465-8545
CITY
Pitt Meadows
POSTAL CODE
V3Y 1A7
MANAGER
Gurdeep Singh

INSPECTION DATE
August 28, 2023
ADDITIONAL INSP. DATE (multi-day)
September 08, 2023
ADDITIONAL INSP. DATE (multi-day)
September 08, 2023
TIME SPENT (HRS.)
3.5
ARRIVAL
01:00 PM
DEPARTURE
03:00 PM
ARRIVAL
09:40 AM
DEPARTURE
10:10 AM
ARRIVAL
10:30 AM
DEPARTURE
11:00 AM
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 as part of a routine inspection:
- Licensing
- Physical Facility
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting


As part of this routine inspection, a facility risk assessment tool is completed. The risk assessment includes contraventions 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
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: - Oven door in Kitchen was broken, of concern is the door does not seem to be closing appropriately and persons in care could injure themselves.
- Downstairs bathroom toilet is missing tank lid, of concern is Persons in care could injure themselves.
Corrective Action(s): A licensee mist regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the ACT and this regulation are being met.
Date to be Corrected: 22-September-2023

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: Observed cut out holes approximately 8" wide in ceiling of one resident bedroom and back room common area.
Corrective Action(s): A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Date to be Corrected: 22-September-2023

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: Light switch in residents room is missing protective face plate. Of concern would be persons in care being exposed to electrical wires and getting injured.
Corrective Action(s): A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Date to be Corrected: 22-September-2023

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): Observed person in cares medication stored in unlocked kitchen cabinet.
Corrective Action(s): A licensee must ensure that (a) all medication in the community care facility are safely and securely stored.
Date to be Corrected: 22-September-2023

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Observed weights for one resident were missing 4 months in the last year, and a second resident was missing 6 months of weights in the last 14 months.
Corrective Action(s): Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Date to be Corrected: 22-September-2023

RECORDS AND REPORTING: 39620 - RCR s.91(2)(c) - In respect of a record referred to in this regulation, a licensee must (c) produce records, on demand, to the medical health officer.
Observation (CORRECTED DURING INSPECTION): Staffing files were not available on site, and documents were not produced in a timely manner.
Corrective Action(s): In respect of a record referred to in this regulation, a licensee must (c) produce records, on demand, to the medical health officer.
Date to be Corrected: 22-September-2023


Comments

Thank you for your time and assistance with completing this inspection.

Please submit a written response by September 22, 2023 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

(Please note: this inspection report was reviewed with the , written on-site and forwarded to the Licensee.)

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
Sep 22, 2023

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