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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-B6SS6K

FACILITY NAME
Primrose Centre for Community Living
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
PNEL-8A2PKD
FACILITY ADDRESS
4807 Georgia St
FACILITY PHONE
(604) 946-0401
CITY
Delta
POSTAL CODE
V4K 2T1
MANAGER
Kevin Reid

INSPECTION DATE
November 23, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
09:45 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo for:

· Additional resources and
· Links to the Legislation (CCALA & RCR)


Contraventions
Previous Inspection - Contraventions observed on FIR #KDHL-ATKS3F have been corrected.
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: 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: During the inspection if the facility it was noted that:
* Many of the kitchen cupboard doors are in poor repair and have laminate coming off
* The garbage bin cupboard is broken - although not used at this time
* Light fixture cover in the kitchen is broken
* Burnt out bulbs in the bathroom used by the community members who access the snoozlin room
* Broken roof drywall in upstairs bathroom - possibly damaged by construction workers

Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: December 21, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: During inspection it was noted that:
* 1 PIC's shower had dirt on the floor and dust and soap residue on the ledge
* In the kitchen the oven and microwave had food and some burnt on residue
* In the kitchen cupboards there was loose pasta and rice in the bottom of one and dust and sticky areas in others
Corrective Action(s): ensure all common areas are maintained in a safe and clean condition
Date to be Corrected: December 7, 2018

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: During inspection of the emergency supplies it was noted that there was rodent feces on the container and the water packages were stored in cardboard boxes that were damaged. (during the inspection the pest company came and placed bait for rodents and will be installing mesh wire to keep rodents out)
Corrective Action(s): Ensure the emergency supplies are inspected and maintained on a regular basis and provide secure storage of the water
Date to be Corrected: December 21, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Dishwasher chemical cleaning agents were stored in an unlocked cupboard in the laundry area which is accessible to PIC's
Corrective Action(s): Ensure all chemicals and cleaning agents are stored in a secure and safe area
Date to be Corrected: December 7, 2018

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Pasta and cereals were stored in open packaging and freezer food was not dated
Corrective Action(s): Ensure food is safely stored in sealed containers and labeled with dates
Date to be Corrected: December 21, 2018


Comments

Thank you to the Management and staff at Primrose for their participation and support during the Routine Inspection

*LO was unable to sign reoprt 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, 2018

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