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

FACILITY NAME
Sakura House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081380
FACILITY ADDRESS
566 Schoolhouse St
FACILITY PHONE
(604) 939-4342
CITY
Coquitlam
POSTAL CODE
V3J 5P3
MANAGER
Bree MacColl

INSPECTION DATE
September 25, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.75
ARRIVAL
10:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

A scheduled 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 - Contraventions observed on FIR #VDAN AE7SKW have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: A new admission did not appear to have appropriate documentation of immunization and Tb status in the care plan
Corrective Action(s): Please ensure that all files contain appropriate documentation for immuniation and Tb status. An Immunization form was provided to the manager.
Date to be Corrected: October 13, 2017

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The temperatures regularly monitored for the kitchen fridge freezer were observed to be frequently in a range from -5 to -13 degrees Celsius. Today the temperature was -5.0 C, this was confirmed by the writer's digital temperature reader as well as the facility thermometer. The pantry freezer temperatures were within recommendable range of -18 to -22 degrees Celsius.
Corrective Action(s): Please provide a plan that will ensure that the results of temperature monitoring are regularly reviewed and action taken.
Date to be Corrected: Oct. 13, 2017

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: No document providing written consent to call a medical or nurse practitioner was observed in the file of a newly admitted resident.
Corrective Action(s): Please provide a plan that will ensure that each resident's file contains the consent described above at the time of admission.
Date to be Corrected: Oct. 13, 2017


Comments

Maintenance of this facility is referred to BC Housing. There is evidence of significant wear and paint loss on the wall hand rails, the tops of some of the fence posts are missing which allows rain to sit in the well at the top of the post, contributing to early rot. Please provide a plan that ensure maintenance is up to date.
The head office will provide information for references, work history, diplomas and certificates, immunization and Tb status. Assuming all documents have been collected appropriately this will act as review of the documents in screening for new hires.
This facility appears clean and orderly. There is a homelike atmosphere in the facility, and each of the residents' rooms is decorated in a manner that reflects the interests of the resident.
I would like to thank the staff and resident who was present for the inspection for their assistance with this 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
Oct 13, 2017

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