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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CG4LTE

FACILITY NAME
917 Foster
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081567
FACILITY ADDRESS
917 Foster Ave
FACILITY PHONE
(604) 937-0609
CITY
Coquitlam
POSTAL CODE
V3J 2L8
MANAGER
Michelle McCormick

INSPECTION DATE
July 06, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
11:50 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
5

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 https://www.fraserhealth.ca/residentialcare 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: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: A PIC required use of a grab bar during toileting. The grab bar was observed to have rust and was not securely held in place.
Corrective Action(s): Ensure that all equipment used by persons in care are maintained in a safe and clean condition.
Date to be Corrected: August 6, 2022

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: Inspection of the physical facility found the following:
- The baseboards throughout the entire home had significant chips and damage caused by wheelchairs.
- The wall located on the east side washroom was observed to have a large amount of paint chipped measuring approximately 4-5 inches in width.
- The hallway located on the west side of the home was observed to have black scuff marks lining the entire hallway caused by wheelchairs.
- The cupboard below the kitchen sink was observed detached from the hinge.
- A section of the fence located on the outside of the home appeared to have 3 wood panels removed.
- The linoleum on the right side of the kitchen sink was peeled off, measuring approximately 2 inches in length.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 6, 2022

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 (CORRECTED DURING INSPECTION): Bleach was found near the emergency supplies storage area and was not kept locked or safely secured.
Corrective Action(s): Ensure cleaning agents, chemical products and other hazardous materials are secure, safe and stored.
Date to be Corrected: August 6, 2022

POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation (CORRECTED DURING INSPECTION): Review of the facilities emergency supplies found 13 canned goods with an expiration date of 2021.
Corrective Action(s): Ensure that items in the emergency kit are checked regularly for expirations dates.
Date to be Corrected: August 6, 2022

POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: 2 of 5 persons in care was observed with bed rails. As a bed rail is classified as a restraint, it would need to be reviewed by a medical practitioner. There was no documentation found in the person in cares care plan to confirm this review had taken place.
Corrective Action(s): Ensure there is an agreement to the use of the restraint given in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: August 6, 2022

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 3 of 5 PIC's weight charts determined that a weight was not captured for the month of March and April and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: August 6, 2022


Comments

I would like to thank the team at 917 Foster for their time and assistance in the completing this inspection. Please submit a written response by August 6, 2022 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements. If you have any questions related to this report please feel free to contact me. Due to infection control practices in place related to COVID-19 prevention, this report was written off-site and is therefore unsigned. The report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Aug 06, 2022

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