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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-CSLL3H

FACILITY NAME
Lakeshore Care Centre
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTUM
FACILITY ADDRESS
657 Gatensbury St
FACILITY PHONE
(604) 939-9277
CITY
Coquitlam
POSTAL CODE
V3J 5G9
MANAGER
Diana Ivette Sanchez Gonzalez

INSPECTION DATE
June 07, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
09:30 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
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 -
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: Licensing observed the water temperature in several PIC's room reached a high of 54.2'C. Staff are monitoring the water with a laser thermometer. A plumber was called and is due to attend the facility today.
Corrective Action(s): A licensee must ensure that water accessible to a person in care, is not heated to more than 49.C
Date to be Corrected: June 8 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 staff files, 1 out of 10 staff did have their immunization record in the file.
Corrective Action(s): A licensee must not employ a person in a community care facility unless the manager has obtained evidence the person has complied with the Province;s immunization and tuberculosis control programs
Date to be Corrected: June 16 2023

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Upon review of staff files, 4 out of 10 staff have not received a performance review.
Corrective Action(s): A licensee must ensure that performance of each employee is reviewed both regularly and yearly as per the facility's policies.
Date to be Corrected: June 16 2023


Comments

Thank you to all the staff for your time and assistance with today's 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
Jun 16, 2023

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