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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AT4Q2U

FACILITY NAME
Shaw House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081611
FACILITY ADDRESS
560 Shaw Ave
FACILITY PHONE
(604) 931-5603
CITY
Coquitlam
POSTAL CODE
V3K 2R1
MANAGER
Clarissa Gamboa

INSPECTION DATE
November 14, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:30 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604 949 7710

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: A lunch was observed with 2 food groups of grain and fruit/vegetables only.
Corrective Action(s): Please ensure that each meal contains 3 food groups.
Date to be Corrected: Nov. 30, 2017

RECORDS AND REPORTING: 39020 - RCR s.70(5)(a) - A licensee must ensure that, if a person in care suffers an adverse reaction to a medication, an employee immediately (a) documents the reaction on the person in care's medication administration record.
Observation: One resident file was observed to have "no allergies" documented in most of the records, but one record showed the PIC to be allergic to loxapine.
Corrective Action(s): Please provide a plan to ensure that all allergy documentation is consistent and accurate.
Date to be Corrected: Nov. 30, 2017


Comments

The facility has previously been repeatedly contravened for continuing damage to the wallboard corner beads and the doors and frames. It is apparent that some progress has been achieved, in that there is new Kydex (?) hard wallboard protector surface and metal strips strategically installed to protect the larger vulnerable surfaces. There is a replacement door, the right hand door as one enters the tub room, that is hollow-core and there is a perforation to the skin caused by a resident lift device. The manager states this was to be a temporary door, but the replacement door has not been installed. Also, the door jam mouldings are excessively damaged to some of the bedroom openings, particularly the room of KY. Please provide licensing with a plan whereby the maintenance to the remaining vulnerable areas can be achieved on a regular basis. Response due Nov. 30, 2017.
The outside activity area was observed. The concrete patio area with seating and shelter from the elements. The grass area was observed to have significant disruptive damage to the surface caused by small animals that have rolled up the sod in many areas. The manager states that the grass area is all but unusable for the residents as the wheelchairs used by all residents cannot be taken onto the grass because it is too soft. Please provide a plan to ensure that appropriate maintenance occurs in the outside space.
There were 2 staff files reviewed. The first-aid/CPR qualifications for the staff were reviewed and were certified for Healthcare providers. Please review the Schedule C available at the back of the Residential Care Regulations to ensure the qualification activities meet with the description of requirements in this Schedule C. Response due Nov. 30, 2017.
Discussion occurred about the provision of ENSURE for one PIC who pays for the product themselves. It was unclear if the product was ordered by the physician or the dietitian. Review of the legislation occurred with the manager who will confirm the origin of the direction to provide the PIC with ENSURE and whether it is the licensee responsibility to pay, as per RCR 67(1)(a) for the product.
Documentation for Food Safe training was not observed for one staff. The staff was contacted and will either bring in their certificate, this was done during the inspection.
I would like to thank the staff who were present and/or assisted with the inspection.
Technical difficulties have interferred with signing of this document.

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
Nov 30, 2017

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