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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AVH2CZ

FACILITY NAME
Quadling House A
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
AKLN-6AGNK5
FACILITY ADDRESS
820 A Quadling Ave
FACILITY PHONE
(604) 936-8456
CITY
Coquitlam
POSTAL CODE
V3K 2A4
MANAGER
Perminder Kaur Palak

INSPECTION DATE
January 29, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
02:30 PM
DEPARTURE
06:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 CCFL website at www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604 949 7710

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-AGM2AC have been corrected except for those noted on supplementary pages.
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: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Washing machine/dryer are housed in a closet on the second floor. The flooring is laminate and there is no evidence of a non-slip surface. The manager states that the residents who use the laundry wear slippers, but the floor would not be non-slip in the presence of moisture.
Corrective Action(s): Please provide a plan that will ensure that there is a non-slip surface on the floor at the time laundry is being done by residents.
Date to be Corrected: Feb. 15, 2018

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: A dentist, nor evidence of dental assessment was not observed in the Share Vision record for one resident.
Corrective Action(s): Please provide a plan that will ensure that all residents receive service from a dental professional at least once a year.
Date to be Corrected: Feb. 15, 2018

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: Status of compliance with the provincial immunization and Tb program was observed as "N/A".
Corrective Action(s): Please provide a plan that will ensure that appropriate documentation is in place for all admissions.
Date to be Corrected: Feb. 15, 2018

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: A roll of Acetaminophen tabs in packaging was observed to be outdated in Nov. 2017.
Corrective Action(s): Please provide a plan that will ensure that all medications will be within the expiry date.
Date to be Corrected: Feb. 15, 2018

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Week 6 and 7 were reviewed for appropriate numbers of food groups for meals and snacks. Some meals and snacks were observed to be deficient in the required number of food groups. This was discussed with the manager. A new Canada's Food Guide was provided to the manager.
Corrective Action(s): Please provide a plan that will ensure that each week of in the 8 week menu is appropriately audited to meet the regulations.
Date to be Corrected: Feb. 15, 2018


Comments

A staff record checklist was reviewed and found in order.
Policies and procedures were not reviewed at this inspection as the CLS policies and procedures are the same for all CLS facilities and are reviewed at random facilities.

Sigvarus stockings were observed under a sink upstairs. The resident the stockings belonged to was not known to have problems with their lower legs. The care plan showed attendance at a Varicose Clinic at St. Paul's Hospital in 2017 before the resident came to this facility. The manager was not aware of the resident having issues with the lower legs. The resident was happy to show the LO the legs. It was apparent there were problems with a healed wound on the inner lower left leg.
Please provide a plan that will ensure that staff are aware of the resident's health status and the education necessary to ensure maintenance of the resident's well-being. Feb. 15, 2018

This facility is tidy and well organized. The decoration reflects the likes and dislikes of the residents. The residents appear comfortable and happy in their interactions with the staff.
Thank you to staff and residents for assistance with the 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
Feb 15, 2018

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