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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MMON-C6GUFJ

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
September 01, 2021
ADDITIONAL INSP. DATE (multi-day)
September 02, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM
DEPARTURE
03:00 PM
ARRIVAL
09:00 AM
DEPARTURE
10:00 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and 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.

Care systems reviewed during inspection include the following: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & Reporting. Staff files were not reviewed at this inspection, as they are kept offsite at the organization's Head Office, and will be reviewed at another time.

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 www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA & 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
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: One person in care's room had approximately six scrapes and gouges on the wall to the depth of exposed drywall. These marks were reported to have been made by person in care's wheelchair. In shower room, the transition strip from the main room floor to shower floor had several long pieces of tape across it, some parts of which were lifting.
Corrective Action(s): Ensure all rooms are in maintained in good repair and are safe for person's in care to mobilize.
Date to be Corrected: September 30, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31610 - RCR s.30(d) - A licensee must ensure that all bathrooms have (d) any other equipment that is necessary to protect the health, safety and dignity of the persons in care.
Observation (CORRECTED DURING INSPECTION): In three bathrooms, the following was observed:
-One bathroom, three body sponges were hanging together on a shower wall, and touching each other. In a second bathroom, two body sponges were hanging together and touching. It was confirmed by employees they were each for different Persons in Care
-One bathroom, there was one unlabelled toothbrush, one unlabelled electric razor, one unlabelled electric nose trimmer, all on shared shelves for more than one person in care
Corrective Action(s): Ensure all items are kept separately and labelled for each person in care
Date to be Corrected: September 2, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): Food storage area had three containers with food which was not in original packaging, labelled or dated.
Corrective Action(s): Ensure all food that has been removed from original packaging is appropriately labelled.
Date to be Corrected: September 2, 2021

MEDICATION: 36040 - RCR s.68(2)(a) - A licensee must appoint a supervising pharmacist to (a) serve on the medication safety and advisory committee.
Observation: The most recent Medication Safety and Advisory Committee meeting minutes provided were dated April 2019.
Corrective Action(s): Ensure the Medication Safety and Advisory Committee meets regularly, including the supervising pharmacist.
Date to be Corrected: September 30, 2021

MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: The most recent Medication Room inspection documentation provided by facility was dated April 2019.
Corrective Action(s): Ensure the supervising pharmacist completes medication room inspections on a regular basis.
Date to be Corrected: September 30, 2021


Comments

For their reference and/or use, facility management was sent a copy of The Health Professions Act Bylaws, Schedule F, part 3. The facility reports they have started working with a new pharmacy, organization wide, which started on September 1, 2021.
Please submit a written response by September 30, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.
This inspection report was not signed by management as it was reviewed with management over the telephone and sent 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
Sep 30, 2021

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