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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-BL8VEU

FACILITY NAME
Eastlawn
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203578
FACILITY ADDRESS
1190 Eastlawn Dr
FACILITY PHONE
(604) 298-7721
CITY
Burnaby
POSTAL CODE
V5B 3H1
MANAGER
Carl Danroth

INSPECTION DATE
January 27, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
01:00 PM
DEPARTURE
04:15 PM
ARRIVAL
DEPARTURE
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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: 31070 - RCR s.16(2)(a) - A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to (a) permit a person to carry out effectively the types of activities that would be reasonably expected in the ordinary use of the room.
Observation: It was noted during inspection that there was burnt out light bulb in one upstairs bedroom, 2 burnt out bulbs in the downstairs living room, 1 non functioning light fixture in the downstairs living room and a partially functioning light fixture in the hallway in front of the downstairs emergency exit.
Corrective Action(s): Please ensure all rooms are lit sufficiently and working
Date to be Corrected: February 10, 2020

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The ramp leading up to the house is showing sings of wear and tear and has a few spots where paint has come off and has some soft areas where the wood is rotting
Corrective Action(s): Please ensure that the ramp is maintained in a state of good repair
Date to be Corrected: April 17, 2020

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Review of the medical records showed that 1 individual was missing records for dental visits since 2018
Corrective Action(s): Ensure that all persons in care see a dental heath professional at least once per year
Date to be Corrected: February 10, 2020

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Upon review of the medication containers it was noted that 2 PRN packages were expired
Corrective Action(s): Please ensure that all expired medications are returned to the pharmacy
Date to be Corrected: February 10, 2020


Comments

There was a significant roof leak approximately 6 months ago that damaged the roof in both the upstairs and downstairs bathrooms. It was noted during inspection that there is paint peeling from the roofs and signs of black mold are showing on the upstairs bathroom ceiling. This is a health risk to the PIC's and is related to this water damages. Through discussion with the manager it was determined that the agency has a plan to repair the house roof and the bathroom ceilings but no concrete date has been confirmed.

Please ensure a health and safety plan is completed prior to beginning work on the roof or bathrooms.

Please provide a date for repairs

Thank you to the Management, Staff and Individuals for their care and dedication to the people they support and their participation in the routine inspection.

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
Feb 10, 2020

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