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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BMUSFX

FACILITY NAME
Foyer Maillard
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
TBIU-9PRU66
FACILITY ADDRESS
1010 Alderson Ave
FACILITY PHONE
(604) 937-5578
CITY
Coquitlam
POSTAL CODE
V3K 1W1
MANAGER
Doris Brisebois

INSPECTION DATE
March 11, 2020
ADDITIONAL INSP. DATE (multi-day)
March 19, 2020
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
12:00 PM
DEPARTURE
04:00 PM
ARRIVAL
11:45 AM
DEPARTURE
02:45 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 (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this Routine Inspection, a Facility Risk Assessment Tool was completed and a copy provided to the Licensee’s representative. 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 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
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: A review of 6 persons in care’s files was completed. As part of a person in care’s wound care plan, treatment plan stated to change a dressing every 2 days and to change dressing every Monday, Thursday and Saturday. Staff failed to implement this plan, as this person in care’s dressing treatment had conflicting frequency.
Corrective Action(s): Please ensure that care plans are monitored and implemented correctly as required.
Date to be Corrected: March 27, 2010


Comments

The Licensing Officer (LO) would like to thank the Manager, Director of Care and staff for their time and assistance in completing this routine inspection.
This report was reviewed and discussed with manager. A copy of this report was left at the facility.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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 27, 2020

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