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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-CSTUF8

FACILITY NAME
Holyrood Manor
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTLK
FACILITY ADDRESS
22710 Holyrood Ave
FACILITY PHONE
(604) 467-8831
CITY
Maple Ridge
POSTAL CODE
V2X 3E6
MANAGER
Beverly Tanseco

INSPECTION DATE
June 19, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
09:30 AM
DEPARTURE
04:30 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
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, 3 out of 6 files did not have an immunization record.
Corrective Action(s): A licensee must not employ a person in a community care facility unless the licensee, or manager have obtained compliance with the Province's immunization control program
Date to be Corrected: June 26 2023

STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Upon review of the staffing files, 4 out of 6 files did not have a performance review conducted annually as per facility policies.
Corrective Action(s): A licensee must ensure that the performance of each staff is conducted regularly as per facility polices.
Date to be Corrected: June 26 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 person's in care files, 6 out of 6 did not have recorded permission to call an ambulance in case of an incident or illness..
Corrective Action(s): A licensee must have and keep with each person in care, consent in writing to call an ambulance in case of an accident or illness.
Date to be Corrected: June 26 2023


Comments

Thank you for your time and assistance with the inspection today

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 26, 2023

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