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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AFYQY7

FACILITY NAME
Shaw House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081611
FACILITY ADDRESS
560 Shaw Ave
FACILITY PHONE
(604) 931-5603
CITY
Coquitlam
POSTAL CODE
V3K 2R1
MANAGER
Clarissa Gamboa

INSPECTION DATE
November 22, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
09:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
6

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 (enter phone # and email)

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-A86N8T 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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The door of a bedside chest was observed to be uncloseable due to a container larger than the space available in the chest. The door appears warped, possibly due to repeated efforts to close it. The latch was not visible. The manager was reminded that the repair of furniture is not the responsibility of the PIC, but the licensee as per this regulation.
Corrective Action(s): Please provide a plan that will ensure that all furnishings are maintained in a good state of repair.
Date to be Corrected: Dec. 7, 2016

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The following maintenance issues were observed:
- at front entrance to property, there are wooden pillars that hold the address numbers. These structures are rotten and falling down, unsafe.
-the window in the southeasterly bedroom is fitted with elongated screws, for unknown purpose, at the mid point in the lower sash. The right hand screw has cracked both the inside and the outside pane of glass thus compromising the argon seal. The manager stated this occurred when the product was installed but was not followed up despite notification at the time.
- the corner bead in the same bedroom is knocked out for a length of approx 2 feet and is 2-4 inches wide in some places. This defect has been observed on 2 previous inspections.
- the window sill next to the medication counter in the kitchen has large spots of paint flaked away.
- The vent in one of the bathrooms was observed to be caked with fuzzy dust.
- in 2 bedrooms, the rheostat dials were missing.
Corrective Action(s): Please provide a plan that will ensure that the house is maintained regularly.
Date to be Corrected: Dec. 7, 2016

POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: Weights of an individual were observed to be missing on 2 occasions. The weight policy was reviewed. It did not contain direction for staff to record the reason the weights could not be done. The manager was able to find the weights for the 2 PIC's. They were written on a calendar page and had not been recorded in the care plan.
Corrective Action(s): Please provide a plan that will ensure that a policy that directs staff in the procedure for taking and recording weights, and that the procedure is appropriately implemented by staff (RCR 85 (1)(d))
Date to be Corrected: Dec 7, 2016


Comments

This Inspection is taking place 2 months early due to an administrative need to rebalance this LO's case load.
This facility appears very clean and well organized. Christmas decorations are in place. Many facility maintenance issues have been observed to have been corrected. There are new systems in place to assist with the care provided within the facility and the management of staff.
On the day of inspection, the residents were demonstrating some respiratory symptoms so the staff elected to provide care in the home.
The fence has been replaced in the back yard. Unfortunately the lawn has been torn up by wildlife, and will not be addressed until spring.
I would like to thank the staff and residents for assistance with this inspection.
Licensing officer was unable to sign due to technical difficulties.

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
Dec 07, 2016

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