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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
BHO-006

FACILITY NAME
Baillie House
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962KWT
FACILITY ADDRESS
11666 Laity St
FACILITY PHONE
(604) 476-7888
CITY
Maple Ridge
POSTAL CODE
V2X 7G5
MANAGER
Jennifer DeForrest (Unit 1) & Kathy Hancock (Unit 2)

INSPECTION DATE
December 13, 2016
ADDITIONAL INSP. DATE (multi-day)
December 14, 2016
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
0.01
ARRIVAL
10:00 AM
DEPARTURE
04:00 PM
ARRIVAL
09:00 AM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction


Contraventions
Previous Inspection -
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation:
Corrective Action(s):
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation:
Corrective Action(s):
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation:
Corrective Action(s):
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31870 - RCR s.69(3)(b)(i) - A licensee must ensure that (b) in the case of a person in care whose short term care plan or care plan provides for the person in care to self-administer medication, the person in care (i) has a safe and secure storage area for medication.
Observation:
Corrective Action(s):
Date to be Corrected:

STAFFING: 32120 - RCR s.40(3) - A licensee must not permit an employee to carry out any duties for which the employee does not have the necessary training and experience or demonstrate the necessary competence.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation:
Corrective Action(s):
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation:
Corrective Action(s):
Date to be Corrected:

MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation:
Corrective Action(s):
Date to be Corrected:

MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation:
Corrective Action(s):
Date to be Corrected:

MEDICATION: 36140 - RCR s.70(4)(b) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (b) included in the care plan of the person in care.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39360 - RCR s.84(c) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (c) the alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation:
Corrective Action(s):
Date to be Corrected:


Comments


Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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