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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
The Salvation Army Buchanan Lodge		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
2501002
FACILITY ADDRESS
409 Blair Ave		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Blake Armstrong
INSPECTION DATE
October 28, 2022		ADDITIONAL INSP. DATE (multi-day)
November 01, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
03:15 PM		DEPARTURE
04:15 PM		ARRIVAL
01:15 PM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

An unscheduled follow up inspection to the Routine Inspection, dated June 24, 27 and 28, 2022, was conducted. Areas of noncompliance identified at the Routine Inspection were reviewed for compliance.
Visit the CCFL website at www.fraserhealth.ca/residentialcare
For additional resources, and links to the Legislation (CCALA and RCR): http://www.gov.bc.ca/residentialcarefacility http://www.fraserhealth.ca/your_environment/ccfl

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32081 - RCR s.37(3)(a) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (a) a criminal record check for the person;
Observation: One volunteer has an expired criminal record check and no CRC application confirmation on file.
Corrective Action(s): A licensee must ensure that all volunteers have a valid criminal record check.
Date to be Corrected: November 15, 2022

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: One medication refrigerator temperature were not recorded 10 times for each month of August, September and October 2022, temperature has to be monitored twice daily.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: November 15, 2022
Comments

Thank you to all the staff for their assistance and cooperation for the routine follow-up inspection completion.

The Licensee has a system in place to monitor the physical facility concerns, person in care requirements, staff requirements and policies & procedure implementation.
The Licensee addressed most of the contraventions from the last routine inspection except for two contraventions that remains outstanding and would require a written response.
The findings were discussed with the leadership when the Licensing Officer was at the site. The copy of the follow-up inspection report was provided through email.

Please provide your written response to Licensing by November 15, 2022.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Nov 15, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.