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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BLHT6D

FACILITY NAME
WIlliam Rudd House
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962L4S
FACILITY ADDRESS
95 Blackberry Dr
FACILITY PHONE
(604) 517-8640
CITY
New Westminster
POSTAL CODE
V3L 5S7
MANAGER
Senija Kolocka

INSPECTION DATE
February 05, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:00 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspect was 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 (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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · 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.
Visit the CCFL website at :http://www.gov.bc.ca/residentialcarefacility
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-AVBP3W 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: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The fridge for use by persons in care (located in the breakfast dining area) was inspected and found to have a temperature log sheet attached that was missing 17 entries from January. Of concern is that the at least 10 of the temperatures that were documented were outside of the recommended range. Upon further inspection it was found that the thermometer was reading at -2 degrees, which may be inaccurate as no items appeared to be frozen.
Corrective Action(s): Please ensure that a functioning thermometer is used to obtain an accurate temperature reading of the fridge. Additionally employees are required to document the temperatures and to also respond in an appropriate manner in the event that the temperature readings are outside of the recommended range to ensure that food is safely stored.
Date to be Corrected: 10 Feb 2020

RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Upon review of 4 care plans, it was identified that one person in care had sustained a fall and required hospitalization. Community Care Facilities Licensing does not have evidence of this incident having been reported as required by the Residential Care Regulations.
Corrective Action(s): Please ensure that all incidents, as defined in Schedule D of the Residential Care Regulations, is reported in the manner required by the medical health officer.
Date to be Corrected: 10 Feb 2020


Comments

This facility is closely associated with Queens Park Care Center (QPCC) and shares multiple services including food and nutrition, human resources (staff files) and recreation staff. These areas were not inspected at this time but will be reviewed during the Queens Park Care Center routine inspection. If any concerns are identified related to William Rudd House, a follow-up inspection will be conducted.

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
Feb 21, 2020

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