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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-BLGTY3

FACILITY NAME
Cedarvale (East)
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081798
FACILITY ADDRESS
23635 118th Ave
FACILITY PHONE
(604) 467-7509
CITY
Maple Ridge
POSTAL CODE
V4R 2C9
MANAGER
Debbie Middleton

INSPECTION DATE
February 03, 2020
ADDITIONAL INSP. DATE (multi-day)
February 04, 2020
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
12:30 PM
DEPARTURE
01:30 PM
ARRIVAL
01:30 PM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

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 #AROE-B55QH2 have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 1 PIC's Oral Health Care Plan was written in October 2016 and has not been updated since.
Corrective Action(s): Please ensure that each care plan is reviewed at least once each year.
Date to be Corrected: March 31 2020

RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: 1 PIC's binder had no TB record in place.
Corrective Action(s): Please ensure that a record is kept of TB status for each PIC.
Date to be Corrected: March 31 2020

RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: 1 PIC was noted to not have a care plan in place. The PIC does have a partial Fraser Health Care Plan (dated January 2019) that is used for certain medical conditions. The PIC moved into the facility almost 2 years ago with numerous assessments and reports that the facility has been working from since then but no standard care plan has been created yet.
Corrective Action(s): Please ensure that a care plan is created for each PIC.
Date to be Corrected: March 31 2020


Comments

During the inspection it was noted that numerous items were being stored in the downstairs living room. The manager stated that this was only temporary and a plan is in place to remove all the items soon.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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