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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-B5ENBD
FACILITY NAME
Holyrood Manor		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTLK
FACILITY ADDRESS
22710 Holyrood Av		FACILITY PHONE
(604) 467-8831
CITY
Maple Ridge		POSTAL CODE
V2X 3E6		MANAGER
Denise Bedard
INSPECTION DATE
October 05, 2018		ADDITIONAL INSP. DATE (multi-day)
October 10, 2018		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
11:00 AM		DEPARTURE
04:00 PM		ARRIVAL
10:15 AM		DEPARTURE
12:15 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo
Contraventions
Previous Inspection - Contraventions observed on FIR #HRM-007 have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: A review of 3 registered staffing files found that 2 did not currently hold a valid first aid certificate. Both had expired in 2017. The manager stated that the facility is planning on having all registered staff attend a first aid course in November,
Corrective Action(s): Please ensure that all PIC's have immediate access to an employee who holds a valid first aid certification.
Date to be Corrected: November 31 2018.

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: A review of 4 tubs rooms found that the cleaning checklists were not being completed as outlined by facility policy.
Corrective Action(s): Please ensure that all policies are being implemented by all employees.
Date to be Corrected: October 31 2018

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: During the inspection it was noted that some clean laundry was being stored in a dirty utility room. This posed the risk of potential contamination.
Corrective Action(s): Please ensure that no items are being stored in the dirty utility room that should not be there and that clean laundry is being stored in areas that do not pose contamination risk.
Date to be Corrected: October 31 2018
Comments
Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required
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Click here for a description of each "Category" of violation displayed.