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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-B62LUS

FACILITY NAME
Chadsey House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0762002
FACILITY ADDRESS
7400 Sunshine Dr
FACILITY PHONE
(604) 858-4331
CITY
Chilliwack
POSTAL CODE
V2R 1H6
MANAGER
Carolyn M. Leadbeater

INSPECTION DATE
October 29, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
11:00 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and 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 include the following:

Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & Reporting
Resident Bill of Rights
Additional CCALA Sections

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 - Contraventions observed on FIR # have been corrected.
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Water temperature from two sources was found to exceed 49 degrees Celsius
Corrective Action(s): Ensure that water accessible to a person in care is not heated to more than 49 degrees Celsius.
Date to be Corrected: 02 Nov 2018

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Review of persons in care records found that one person in care was last seen by dental health professional in 2016.
Corrective Action(s): Ensure persons in care are encouraged to been seen by a dental health professional annually.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: Review of persons in care records found one persons records did not include a falls prevention plan and risk assessment for falls. Discussion with the manager confirmed that there were measures in place to mitigate risk of future falls, however there was no documentation in the care plan to address the assessment and plan regarding falls.
Corrective Action(s): Ensure there is a risk assessment for falls and a falls prevention plan documented within the care plan.
Date to be Corrected: 02 Nov 2018


Comments

The Community Care and Assisted Living Act and pursuant Residential Care Regulations set the minimum standards that must be met by all licensees of licensed care facilities to ensure the health and safety of vulnerable individuals in care. The responsibility rests with Chadsey House to provide for the health and safety needs of all individuals in your care at all times.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Nov 02, 2018

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