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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

CRAU-AWGQWB

FACILITY NAME 5984 - 191A Street		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0920056
FACILITY ADDRESS 5984 191A St			FACILITY PHONE (604) 574-7229
CITY Surrey	POSTAL CODE V3S 7N1		MANAGER Barbara Coad

INSPECTION DATE March 02, 2018	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.08
ARRIVAL 09:10 AM	DEPARTURE 12:15 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED 4

Introduction

An unscheduled routine inspection was completed with the Program Coordinator to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DLSP). 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

* Policies and procedures

* Care and supervision

* Hygiene and Communicable disease control

* Medication

* Nutrition and Food Services

* Program

* Records and reporting

As part of this 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.

Please visit the Community Care Facilities Licensing (CCFL) website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:

* Additional resources, and

* Links to the legislation (CCALA and RCR)

Contraventions

Previous Inspection - Not Applicable

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

Observed Violations

LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: For example the following need to be addressed after reviewing one person in care's records/care plan:

*Food and Nutrition Record on the computerized system is noted with the year 2016. The Program Coordinator stated this will be updated.
Corrective Action(s): Please ensure that regular monitoring of the care and services is being implemented to ensure that the requirements of the Act and Residential Care Regulation are being met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

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: For example the following items need to be addressed:

1. Kitchen noted in sevaral areas on the cabinets where there is tape noted and the Program Coordinator demonstrated the laminate on the top of the cabinets is starting to peel off in the corners for example.

2. The flooring right outside the ktichen noted with what appears to be black coloured marks in several areas and the Program Coordinator demonstrated the top of the flooing is peeling off.

3. In the shower room the drain when stepped on appears to be soft as demonstrated by the Program Coordinator. In addition, the tiles around the drain have come off are loose. The Maintenance Staff for the Licensee tried addressing the tiles previously and viewed the bottom of the shower through the crawl space and indicated the area underneath the shower is soft likely due to moisture.

The above three items have been reported to BC Housing as advised by the Program Coordinator.

4. In the tub room, the Program Coordinator stated previously when a person in care was to be bathed, the tub side arm was raised and it hit the ceiling and now a few holes are in the ceiling.
Corrective Action(s): Please ensure all common areas are maintained in a good state of repair.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: A random review of one staff's documentation on the computerized system indicated that their performance appraisal was to have been completed in 2017 (exact date noted on the computerized system and as discussed with the Program Coordinator. The Program Coordinator indicated that performance appraisals are not all up to date.
Corrective Action(s): Please ensure performance appraisals are completed on a regular basis.
Date to be Corrected: Please provide a written response to this item by the timeline noted in the report.

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: As per Section 40(1)(a) of the Residential Care Regulation.
Corrective Action(s): As above.
Date to be Corrected: As above.

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 random review of one person in care's records/care plan indicated they don't have a tuberculosis assessment on file. The Program Coordinator stated this may be in the old documents for the person in care.
Corrective Action(s): Please ensure all persons in care have a tuberculosis assessment completed and follow-up depending on the assessment occurs as is required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.

Comments

Policies and Procedures;

- The required policies and procedures required by the Residential Care Regulation have been reviewed and/or revised as the Program Coordinator discussed with the Licensee Contact. The dates on the policies and procedures will be put in-place by the end of the day on March 2, 2018. Please provide confirmation in-writing when the policies and procedures have been noted with updated dates.

- House calendar needs to be updated on the computerized system. Please let the writer know the plan to address this.

- Screening form for when to get the Dietitian involved for one person in care the scoring at the bottom of the document will have "yes" or "no" completed. Please ensure staff are completing documentation in full where applicable. Please let the writer know when this will be addressed.

Thank you for your time to complete today's routine inspection.

If there are any questions regarding this report, please contact your Licensing Officer.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	Follow-up Inspection Required
Due Date Mar 16, 2018	Approximate Follow Up Date 30 Mar, 2018

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