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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME Shaw House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081611
FACILITY ADDRESS 560 Shaw Ave			FACILITY PHONE (604) 931-5603
CITY Coquitlam	POSTAL CODE V3K 2R1		MANAGER Clarissa Gamboa

INSPECTION DATE January 23, 2019	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 10:30 AM	DEPARTURE 02:30 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

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 #VDAN-AT4Q2U 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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius. Observation: In 3 areas of the house the water was tested. Bath #1 - 62.0 degrees, Bath #2 - 61.8 degrees, Kitchen - 62.5 degrees Corrective Action(s): Ensure water temperature is not heated more than 49 degrees Celsius Date to be Corrected: January 25, 2019 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: Upon inspection of the kitchen it was noted that many of the cupboards were dusty and greasy inside and some food crumbs were noted in the bottom of the cupboards Corrective Action(s): Ensure that all areas are maintained in a safe clean condition Date to be Corrected: February 1,2019 POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Upon review of the MAR binder for 6 PIC's, a PRN for 1 PIC was not documented in the nurses notes for 6 administrations Corrective Action(s): Ensure all PRN medication administration is documented in the nurses notes Date to be Corrected: February 1, 2018 HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene. Observation: Commodes in the shower room and the seat mats in the tub room were not labeled with the PIC's names Corrective Action(s): ensure all personal items used in common areas for personal hygiene are labeled with the PIC's names Date to be Corrected: February 8, 2019 HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled. Observation: It was noted that there were waffles and a bagel in the freezer that were not labeled or dated and oil was stored in a container that was unlabeled Corrective Action(s): Ensure all food is safely stored Date to be Corrected: February 8, 2019

Comments

Through conversation with the manager it was noted that at the end of February BC housing would be starting construction and renovations on Shaw house. Most of the physical facility concerns will be addressed in this renovation and thus are not deemed a contravention at this time. A health and safety plan will be submitted to Licensing for approval prior to construction start. A dump run is scheduled to remove and dispose of a few broken items stored on the back patio.

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 Feb 08, 2019

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