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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CQ7RYU
FACILITY NAME
Campbell House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
TDAH-7Z8QHB
FACILITY ADDRESS
21351 Campbell Ave		FACILITY PHONE
(604) 463-7101
CITY
Maple Ridge		POSTAL CODE
V2X 7G6		MANAGER
Kim Rilka
INSPECTION DATE
March 23, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
10:30 AM		DEPARTURE
01:40 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
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). 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
· Policies & 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/health-topics-a-to-z/residential-care-licensing

Residential Care Regulation
Community Care and Assisted Living Act
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: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: One PRN medication administered was not documented in the MAR and one PRN medication effectiveness was not recorded to one person in care.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: April 6, 2023

POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: The emergency menu was not available during inspection.
Corrective Action(s): A licensee must have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Date to be Corrected: April 6, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: One of 4 PICs has no evidence of compliance to Province's immunization but has the tuberculosis risk assessment form on file.
Corrective Action(s): A licensee must require all person admitted to community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: April 6, 2023

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): Two person in care's medications were found passed its expiry date.
Corrective Action(s): Please ensure to return person in care's medication to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: March 23, 2023
Comments

Thank you to all the staff for their assistance and cooperation with the completion of this routine inspection.
The findings were discussed with the facility leadership and the report was written and signed at the site.
The copy of the report and risk assessment were provided via email.

Please submit a written response to this routine inspection to Licensing by April 6, 2023.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Apr 06, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.