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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME Chadsey House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0762002
FACILITY ADDRESS 7400 Sunshine Dr			FACILITY PHONE (604) 858-4331
CITY Chilliwack	POSTAL CODE V2R 1H6		MANAGER Carolyn M. Leadbeater

INSPECTION DATE November 03, 2016	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3
ARRIVAL 01:00 PM	DEPARTURE 04:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s(LO) observations, review of facility records and information provided by facility staff at the time of the inspection. As part of the Routine Inspection a 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. A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights. Visit CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to legislation (CCALA and RCR)

Contraventions

Previous Inspection - Not Applicable

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide. Observation: Review of current menu there was only one food group documented. Corrective Action(s): The Manager stated they have just switched to the winter menu and they will review the weeks to ensure more than one food group is offered for 2 of the snacks as 3 are offered. Date to be Corrected: November 30, 2016 RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer. Observation: The Manager informed they had conducted an internal investigation in August 2016 related to an incident of missing monies of person in care, comfort funds. Licensing informed this incident would be considered a Reportable Incident and should have been reported accordingly. For the individuals affected, money was replaced and financial accounting procedures changed. Staff now count monies at each shift change which means counts are completed 3 times daily. Corrective Action(s): Licensing reviewed reporting requirements and incident definitions with the Manager. Date to be Corrected: November 3, 2016

Comments

Licensing requests a written response be submitted on or before November 14, 2016 describing how the above noted contraventions have been appropriately addressed please include a time for when compliance will be met if applicable. Copies of the inspection report and the Risk Assessment Tool were reviewed, discussed, and provided to the Manager. If you have any questions regarding this report please contact your Licensing Officer.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Nov 14, 2016

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