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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-CUHM3A
FACILITY NAME
Cartier House Care Centre		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
1081802
FACILITY ADDRESS
1419 Cartier Ave		FACILITY PHONE
(604) 939-4654
CITY
Coquitlam		POSTAL CODE
V3K 2C6		MANAGER
Carolina Reyes
INSPECTION DATE
August 08, 2023		ADDITIONAL INSP. DATE (multi-day)
August 09, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
10:00 AM		DEPARTURE
04:00 PM		ARRIVAL
10:30 AM		DEPARTURE
12:30 PM		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 noncompliance 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: 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 the staffing records, 1 out of 8 staff had not yet had a performance review within the 3-6 months of hire date as per the facility's policy requires
Corrective Action(s): A licensee must ensure performance reviews of each employee is reviewed regularly and as per facility polices
Date to be Corrected: August 16 2023


Comments

Thank you to all staff that provided assistance during this 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
Aug 16, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.