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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B97VRE

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) 517-8609
CITY
New Westminster
POSTAL CODE
V3L 5S7
MANAGER
Senija Kolocka

INSPECTION DATE
February 08, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:45 PM
DEPARTURE
05:00 PM
ARRIVAL
DEPARTURE
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). 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 604 918 7526 or 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: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Damaged paint surfaces were observed throughout the facility with especial note taken of Room 3 - a hole - 8"x 8" above floor coving beside the door to the left of the sink, framing around the closet, left side, Rm. 3, SPA room a missing bracket with no repair of the wall behind and to the right of the toilet, paint peeling under towel rail Rm.12, missing towel bar, brackets remain in place in one bathroom.
Corrective Action(s): Please provide a plan that will ensure that the functions and appearance of the rooms continue to support the safety and dignity of the PICs.
Date to be Corrected: Mar. 1, 2019

RECORDS AND REPORTING: 39490 - RCR s.88(a) - A licensee must keep a record of all of the following: (a) minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents.
Observation: Conversation with staff indicated that there is no definition or system for making a record of minor accidents, illnesses, medication errors that do not require medical attention.
Corrective Action(s): Please provide a plan including direction provided by policy that will address the Regulation quoted above.
Date to be Corrected: Mar. 1, 2019

RECORDS AND REPORTING: 39520 - RCR s.89(1) - A licensee must keep a record respecting complaints made and concerns expressed to the licensee under section 60 [dispute resolution], and the responses to them.
Observation: Discussion with staff indicated that they were not aware of any means of recording minor disputes, concerns or complaints.
Corrective Action(s): Please provide a plan that is consistent with facility policy to meet the regulation identified above.
Date to be Corrected: March 1, 2019


Comments

There is a weekly menu posted at the entrance. It is also noted that on 2 days per week, there is arrangement in the main menu for "special menu". This is a menu prepared by the head chef at QPCC that is decided by the residents of William Rudd. Otherwise, the residents "order in" special meals to relieve the monotony of cycling a 4 week menu. Nutrition monitoring is conducted by the dietitian who works out of Queen's Park Care Centre. The residents of William Rudd are welcome at the special events such as pub nites, teas, entertainment with snacks etc that occur at QPCC.
Each room was reviewed. The rooms reflect the interests of the individual resident. They are clean and organized.
The staff records, including volunteers, have not been reviewed at this inspection, information will be provided by the RCC or HR to ensure that hiring and monitoring practices are consistent with the regulations.
The facility activities are managed by the Activity Coordinator at Queens Park Care Centre.
Thank you to residents and staff for assisting with the 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
Mar 01, 2019

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