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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBOI-AZPU5N

FACILITY NAME
Victoria Rest Home Ltd.
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
2504123
FACILITY ADDRESS
731 Queens Ave
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Holden F. Hoogland

INSPECTION DATE
June 13, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
01:00 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# CHILDREN ENROLLED

Introduction

A scheduled follow up inspection to Routine Inspection #KBOI-ATQQ88 dated November 27th was conducted. Areas of non-compliance identified at the Routine Inspection were reviewed for compliance.
Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

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

Observed Violations
POLICIES AND PROCEDURES: 33320 - RCR s.85(2)(b) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (b) the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Observation: Review of the orientation policy found that it has not yet been updated to include orientation of a new manager.
Corrective Action(s): Ensure that an orientation policy is created for managers
Date to be Corrected: August 15, 2018

CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of the weight charts continues to show significant weight fluctuations in a short period of time, without evidence of follow up. One PIC's weight in Jan 2018 was 157, then his weight was missed in Feb, Mar,Apr and in May it was 176 lbs. Another PIC was 149lbs in March 2018 and 132lbs in April 2018. Another PIC's weight was 146lbs in Feb 2018 and by April 2018 was 165lbs. Another PIC's weight in May 2018 was 174lbs and in June was 162lbs. The MOC has some concerns about the scale and/or the consistency of the way the weights are being taken, as observationally the PIC's do not seem to be fluctuating that much.
Corrective Action(s): Ensure that correct weights are taken, and significant weight changes are followed up on.
Date to be Corrected: August 15, 2018


Comments

"When to call the Coroner" has not yet been communicated to staff, but will be on the agenda for an upcoming staff meeting. The MOC who manages critical incidents is aware of when to call.

Some of the meat has been labelled for dates and the system of freezer / fridge items are for them to be rotated out weekly to be used according to the menu. There was no evidence of freezer burned or spoiled items.

Thank you to the MOC for his time during the inspection today, and for all the work that has been done since the last inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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