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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-CT3HN6

FACILITY NAME
Alice Lake Place Group Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1003558
FACILITY ADDRESS
2724 Alice Lake Pl
FACILITY PHONE
(604) 941-4918
CITY
Coquitlam
POSTAL CODE
V3C 5W8
MANAGER
Maivon Thomas

INSPECTION DATE
June 23, 2023
ADDITIONAL INSP. DATE (multi-day)
July 06, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.15
ARRIVAL
09:30 AM
DEPARTURE
09:45 PM
ARRIVAL
10:00 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), the Residential
Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include:
· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records & 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).

Contraventions
Previous Inspection - Not Applicable
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: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Cleaning agents were observed to be accessible to person's in care under the kitchen sink. Staff informed that cleaning agents were to be stored in a different locked location.
Corrective Action(s): A licensee must provide secure, safe and adequate storage areas for cleaning agents.
Date to be Corrected: July 13 2023

STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Upon review of the staffing files, 1 out of 4 staff have not completed a Criminal record check under the Criminal records review act.
Corrective Action(s): A licensee must not employ a person in a community care facility unless the a criminal record check for that person has been obtained.
Date to be Corrected: July 13 2023

STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Upon review of the staffing files, 2 out of 4 did not have evidence to comply with the Province's immunization control program. 1 out of 4 did not have evidence of complying with the Tuberculosis control program.
Corrective Action(s): A licensee must not employ a person in a community care facility unless evidence has been obtained that persons have complied with the Provinces immunization and tuberculosis control program.
Date to be Corrected: July 13 2023

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Upon review of the persons in care's records, no consent in writing was present by the family or representative to call a medical practitioner, nurse practitioner or ambulance in case of an accident or illness.
Corrective Action(s): A licensee must have consent in writing from the family or representative to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness
Date to be Corrected: July 13 2023

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: Upon review of the facility food substitution records, it was found that no recordings have been made since March 2022. It was confirmed by staff that substitutions are being made and that these changes are not being recorded.
Corrective Action(s): A licensee must keep a record of menus and menu substitution.
Date to be Corrected: July 13 2023


Comments

Tour of the facility and observed 2 of the PIC's were out at day programs. The other two PIC's would also be leaving soon for activities and therefore no staff or PIC's would be present in the home. Licensing will return on another date to finish inspection
Licensing returned to complete the inspection, thank you to staff for their assistance during this time.

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
Jul 13, 2023

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