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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CP3UDA

FACILITY NAME
Belvedere Care Centre
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
SENG-8YCRSW
FACILITY ADDRESS
739 Alderson Ave
FACILITY PHONE
(604) 939-5991
CITY
Coquitlam
POSTAL CODE
V3K 1T9
MANAGER
Annamae Clarke

INSPECTION DATE
February 14, 2023
ADDITIONAL INSP. DATE (multi-day)
February 15, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10.5
ARRIVAL
11:00 AM
DEPARTURE
03:15 PM
ARRIVAL
09:15 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Visit the CCFL website at https://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: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: Review of 9 employee files determined that 3 of 9 files show evidence of 1 character reference check and 1 of 9 files did not have any evidence of character reference checks competed.
Corrective Action(s): Please ensure that character references are obtained for all employees.
Date to be Corrected: March 1, 2023

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: In two months there were 6 instances where the effects of a PRN medication were not documented in the Medication Administration Record.
Corrective Action(s): Please ensure that employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 1, 2023

RECORDS AND REPORTING: 39430 - RCR s.86(c) - A licensee must keep the following records in respect of each employee: (c) compliance with the Province's immunization and tuberculosis control programs.
Observation: Review of 9 employee files determined that 1 of 9 files did not have evidence of historical immunizations.
Corrective Action(s): Please ensure that records are kept, in respect of each employee, to show compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: March 1, 2023


Comments

This Licensing Officer would like to thank the Staff for their assistance in completing this routine inspection.


Please provide a written response by March 1, 2023 indicating the corrective actions taken and/or time line and plan to meet legislative requirements.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was reviewed with the manager on site and signed. It was then forwarded with the corresponding risk assessment to the Licensee via email.)

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
Mar 01, 2023

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