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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

SCLY-AGE28K

FACILITY NAME Fleet Street Group Home		SERVICE TYPES 140 Community Living	FACILITY LICENSE # LBAA-8CFSTG
FACILITY ADDRESS 2994 Fleet St			FACILITY PHONE (604) 944-0408
CITY Coquitlam	POSTAL CODE V3C 3R8		MANAGER Luis de Sousa

INSPECTION DATE December 05, 2016	ADDITIONAL INSP. DATE (multi-day) December 06, 2016		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 12:00 PM	DEPARTURE 02:00 PM	ARRIVAL 02:30 PM	DEPARTURE 04:30 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 · Policies and Procedures · Care and Supervision · Hygiene and Communicable Disease Control · Medication · Nutrition and Food Services · Program · Records and Reporting As part of this 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/your_environment/ccfl for: Additional resources, and Links to the Legislation (CCALA and RCR)

Contraventions

Previous Inspection - Contraventions observed on FIR # have been corrected.

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

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: 1 out of 2 Person in Care (PIC) care plans did not have written consent to call a medical/nurse practitioner or 911. Corrective Action(s): Please ensure that each PIC has written consent to call a medical practitioner, nurse practitioner, or ambulance in case of accident or illness. Date to be Corrected: December 23, 2016

Comments

The facility is in the middle of repairs to the facility that were contravened on the previous routine inspection. The repairs were supposed to be finished, but due to poor weather is going to take longer. Licensing will come back to see the facility once the repairs are finished. Listening is going to provide the manager with an example of a consent form for individuals who have no family to sign on their behalf. Due to poor weather conditions the licensing officer conducted this inspection over two days.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required

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