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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JBAY-C4XSWY

FACILITY NAME
917 Foster
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081567
FACILITY ADDRESS
917 Foster Ave
FACILITY PHONE
(604) 937-0609
CITY
Coquitlam
POSTAL CODE
V3J 2L8
MANAGER
Michelle McCormick

INSPECTION DATE
July 15, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
09:30 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
5

Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), 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 include:
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 - Contraventions observed on FIR #AKUR-BKPNHZ have been corrected.
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The facility's water temperature in the bathroom with the walk-in shower was observed to be 52.6° Celsius (a repair ticket to have the water temperature adjusted was submitted during the inspection).
Corrective Action(s): Ensure that water accessible to persons in care, from any source, is not heated to more than 49° Celsius.
Date to be Corrected: July 16, 2021

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: An inspection of the physical facility found the following:
1) A 20 cm piece of trim in the living room (near the front door) was observed to be broken exposing a hole behind.
2) In the bathroom with the walk-in shower, a piece of tile baseboard was observed to be missing exposing the drywall behind.
3) In the bathroom with the tub, caulking was observed to be missing from the tub surround which is needed to prevent water from leaking between the surround and the wall. Additionally, a grab bar near the toilet was observed to be rusted making it difficult to clean.
4) In the hallway leading to the bedrooms, the linoleum was observed to be split in two spots (both spots were approximately 30 cm in length).
5) The fence on the west side of the yard was observed to have three panels with loose boards and one panel missing a board. Additionally, the fence was observed to be leaning approximately 20 to 30 cm into the yard.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 12, 2021

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: An inspection of the physical facility found that one plug cover plate was broken exposing the plug behind.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition (a repair ticket was submitted to fix this during the inspection).
Date to be Corrected: July 15, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: A closet used to store cleaning agents and other hazardous materials what observed to be unlocked and left open.
Corrective Action(s): Ensure that cleaning agents, chemical products and other hazardous materials are safely and securely stored (corrected during inspection).
Date to be Corrected: July 15, 2021

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: An inspection of the facility's emergency supplies found that there was not enough water to sustain persons in care and staff for three days in the event of an emergency.
Corrective Action(s): Ensure that an emergency plan sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Date to be Corrected: July 29, 2021

POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: A person in care (PIC) was observed to be wearing mittens used to prevent scratching (which was in the PIC's care plan); however, there was no evidence that a medical practitioner or nurse practitioner responsible for the health of the PIC had agreed to this in writing.
Corrective Action(s): Ensure that there is agreement in writing to the use of a restraint given by either the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: July 22, 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: An inspection of the facility's kitchen fridge found that three items in the freezer (not in their original packages) were not labelled or dated and two items in the freezer were in freezer bags which were open (corrected during inspection).
Corrective Action(s): Ensure that all food is safely stored.
Date to be Corrected: July 15, 2021


Comments

Licensing Officers would like to thank management and staff for their assistance in completing this routine inspection.
Please submit a written response by July 29, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.
This inspection report was not signed by management as it was reviewed with management over the telephone and sent via email to the site to reduce the amount of time the licensing officers had to spend on site as per COVID-19 prevention measures.

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
Jul 29, 2021

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