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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BGTQAK

FACILITY NAME
Edmonds House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203599
FACILITY ADDRESS
7731 Wedgewood St
FACILITY PHONE
(604) 521-7857
CITY
Burnaby
POSTAL CODE
V5E 2E5
MANAGER
Ronald Cuevas

INSPECTION DATE
October 10, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
09:00 AM
DEPARTURE
01:30 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

· 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: It was observed in the home that there were a number of areas where maintenance is needed.
-In all bedrooms that the window caulking was black and cracking and showed signs of mildew growth.
-Storage room door had the lower molding was peeling off.
-Numerous scuff marks on the wall in a person in care's bedroom.
-Bathroom cabinet appeared to have water damage.
Corrective Action(s): Ensure that all rooms are maintained in a good state of repair.
Date to be Corrected: 08 Nov 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: Upon inspection of this home it was observed that there were numerous areas that were not sufficiently maintained in a clean condition. As discussed with the manager the staff typically clean the home, however there was not a schedule in place for regular cleaning nor a checklist in place for areas that require attention. Areas of concern during this inspection included:
-window sills and windows
-bathroom cabinet
-cobwebs observed in all bedrooms
-one person in care's (PIC) bedroom door was visibly soiled
-kitchen chair had a sticky seating surface
-stove element rings had burnt on spills
Corrective Action(s): Ensure that all rooms and common areas are maintained in a clean condition.
Date to be Corrected: 18 Oct 2019

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: It was observed that there were 2 toothbrushes in the bathroom cabinet that were no labeled to identify whom they belonged to and they were both placed on a shelf that was soiled with dust, hair and dried toothpaste.
Corrective Action(s): Ensure that there is program in place to assist PIC's in maintaining health and hygiene.
Date to be Corrected: 18 Oct 2019

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: It was observed that there was an expired medication, date May 2019. There did not seem to be a self- monitoring system in place to ensure expired medications are returned to the pharmacy.
Corrective Action(s): Ensure all required medications are returned to the pharmacy.
Date to be Corrected: 18 Oct 2019

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: There was no food substitution list available for review.
Corrective Action(s): Ensure that a substitution list is maintained and available for review.
Date to be Corrected: 18 Oct 2019


Comments


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 18, 2019

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