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

FACILITY NAME
Quadling House B
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
AKLN-6AGPWH
FACILITY ADDRESS
820 B Quadling Ave
FACILITY PHONE
(604) 931-3673
CITY
Coquitlam
POSTAL CODE
V3K 2A4
MANAGER
Marcela Herrera

INSPECTION DATE
December 14, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
09:00 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

This is a scheduled routine inspection conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (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
Policies and Procedures
Care and Supervision
Jygiene and communicable disease control
Medication
Nutrition and Food Services
Programs
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 "hisrtorical" 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 and RCR)

If you have questions regarding this report feel free to contact me at:
tel.: 604-949-7710
email: valerie.dairon@fraserhealth.ca

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

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: The following equipment was observed to be in need of repair;
light bulb burnt out in main floor bathroom,
bicast leather recliner, worn seat,
handle of kitchen cupboard door missing a screw,
window seals broken in south west bedroom making 2 large windows opaque,
storage hassock in living room, leather worn,
bicast leather seating for 2 sofas is worn through to fabric in many places,
Dining chair was observed to have loose joints,
kitchen counter to the right of the sink and the right of the stove is damaged, manager states these are scheduled for replacement at an unknown date.
Corrective Action(s): Please provide a plan that will ensure that equipment and furnishings are maintained in a good state of repair
Date to be Corrected: Jan. 3, 2017

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: Painted surfaces throughout the house are chipped, scuffed and worn off.
Corrective Action(s): Please provide a plan that will ensure that rooms and common areas are kept in a good state of repair.
Date to be Corrected: Jan. 3, 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: Review of sanitizing procedures for food preparation surfaces indicated that while surfaces are wiped with disinfectant twice daily, the antibacterial product is not left in place for the required 10 minutes at full strength as required on product directions.
Corrective Action(s): Please provide a plan that will ensure that all staff are familiar with the product directions for achieving effective sanitizing of surfaces.
Date to be Corrected: Jan. 3, 2017

RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: Of 2 PICs' records reviewed, an admission height was not found for one resident.
Corrective Action(s): Please provide a plan to ensure that there is a record of either the admission height and weight for each resident or a record identified as the oldest known height and weight for the residents.
Date to be Corrected: Jan 3, 2017

RECORDS AND REPORTING: 39430 - RCR s.86(c) - A licensee must keep the following records in respect of each employee: (c) compliance with the Province's immunization and tuberculosis control programs.
Observation: A spreadsheet review of the staff did not indicate the status of staff compliance with the BC Immunization program. This does not include flu shots
Corrective Action(s): Please provide a plan that will ensure that there is evidence that all staff are compliant with the BC Provincial Immunization Program
Date to be Corrected: Jan 3, 2017


Comments

Policies and Procedures were not reviewed at this inspection as all CLS facilities use the same policies throughout and these have been reviewed at other inspections.
The new hand written menu plan has not been audited at this point, but is in progress as the menu development is not yet complete. Several meals and snacks from week 2 were reviewed and appear to offer 3 food groups for meals and 2 food groups for snacks.
The resident satisfaction audits and the meal service audits have been completed in June 2016.
The staff spreadsheet did not contain evidence that 2 staff had completed Food Safe. The manager states she has trained these staff, and that most of the staff had completed the on line "Caring About Food Safety". Information for the site was provided to the manager for future use.
This facility changed pharmacy services last year and as part of the new pharmacy process all staff received orientation training for medication administration.
The issue of fall prevention planning was reviewed with the manager. There has been only one fall with this current group of residents, and that occurred after sedation for a hospital procedure for one resident on their return home. This resident does not have regular or PRN sedation in their medication list. The manager will enter this risk in the care plan, as well as doing a risk assessment for the benefit of the PIC and staff in the event of future hospital sedation procedures.
It was a pleasure to inspect this facility. It appears clean and well organized. The resident rooms are well furnished and decorated in a way that reflects each person's unique interests.

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
Jan 03, 2017

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