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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-C4VQK5

FACILITY NAME
Holly
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3203584
FACILITY ADDRESS
7473 Holly St
FACILITY PHONE
(604) 526-5216
CITY
Burnaby
POSTAL CODE
V5E 2C3
MANAGER
Xavier Luck

INSPECTION DATE
July 06, 2021
ADDITIONAL INSP. DATE (multi-day)
July 07, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:00 AM
DEPARTURE
12:00 PM
ARRIVAL
11:00 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled 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). 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 & 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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo for:

· Additional resources and
· Links to the Legislation (CCALA & RCR)

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: 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: The following were observed:

1). The main bathroom on the upper level has rust around the window sill and around the bath tub. This bathroom used by 2 PICs as evidenced by the stored personal items and confirmed by the staff.

2). The backyard has overgrown mixed berry bush covering at least 1/4 of the backyard from both corners. As per the staff person assisting with the inspection a maintenance request has been made to remove the bush.

Corrective Action(s): Please ensure that the bathroom and the outdoor areas are maintained in good state of repair.

Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: 2 sets of bedroom furniture was found stored in the living room. Of concern is the unsafe storage of the furniture and the reduced useable space for the PICs in the living room. As per the staff assisting with the inspection, a new PIC has moved in and the furniture belonging to previous PIC was being removed and disposed slowly.

Corrective Action(s): Please ensure that common areas are maintained in a safe condition at all times.

Date to be Corrected:

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: One PIC who had sustained fall resulting in hospital transfer did not have updated care plan to guide staff on the fall preventive measures in place.

Corrective Action(s): Please ensure that the care plan is reviewed and modified if there is significant change in the status of the person in care.

Date to be Corrected:


Comments

The director of operations was present at the facility and informed the licensing officer that the facility is looking into renovating the steps and the patio upstairs. The new House Manager was present on day 2 of the routine inspection and Licensing was informed that it was the new manager's first day at the facility. I want to thank the staff, the Manager and the director for their assistance with this inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jul 30, 2021

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