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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-AZNNZU

FACILITY NAME
Cartier House Care Centre
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
1081802
FACILITY ADDRESS
1419 Cartier Ave
FACILITY PHONE
(604) 939-4654
CITY
Coquitlam
POSTAL CODE
V3K 2C6
MANAGER
Carolina Reyes

INSPECTION DATE
June 05, 2018
ADDITIONAL INSP. DATE (multi-day)
June 07, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
12:00 PM
DEPARTURE
04:15 PM
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
Links to the Legislation (CCALA & RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR #NBIH-AMWVTC have been corrected except for those noted on supplementary pages.
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 the following was noted:
-The 1st floor dining room had numerous areas of chipped paint work on the walls.
-The 3rd floor patio paint work was chipped and the wooden posts were starting to show evidence of rotting.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 31 2018

STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: A review of 6 staffing files found 1 that did not have a current criminal record check (expired 2016).
Corrective Action(s): Please ensure that a criminal record check is obtained and kept on file for all employees.
Date to be Corrected: July 31 2018

STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: A review of 6 staffing files found that:
-2 staff had no references on file.
-1 staff had only 1 reference on file.
Corrective Action(s): Please ensure that the facility does not employ a person without first receiving 2 references.
Date to be Corrected: July 31 2018

STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: A review of 6 staffing files found that 1 food service staff did not have a current food safe training certification (expired May 2018).
Corrective Action(s): Please ensure that all employees responsible for the preparation and delivery of food have the necessary training to ensure that food is safely prepared and handled.
Date to be Corrected: July 31 2018

POLICIES AND PROCEDURES: 33030 - RCR s.48(1)(c)(i) - Before admitting a person to a community care facility, a licensee must advise the person, or the person's parent or representative, of (c) how the person, or the person's parent or representative, may express concerns or make complaints to (i) a medical health officer.
Observation (CORRECTED DURING INSPECTION): During the inspection and review of the intake package no evidence could be found of how a PIC or representative could express concerns/complaints to a Medical Health Officer / Licensing.
Corrective Action(s): Please ensure that PIC's/representatives are informed of how to make complaints to a medical health officer/licensing at the time of intake.
Date to be Corrected: July 31 2018


Comments

The manager informed licensing that quotes have been obtained for new flooring throughout the facility.
The closet curtain rod issue that was identified in the recent complaint inspection has been resolved.
The facility currently has the dietitian fulfilling the role of the Food Services Manager while the contracted cook works through the qualification course (expected to be completed in 2020). This arrangement is due to run out at the end of June 2018. Please provide Licensing of an update on who will be in the Food Services Manager role until the cook has completed the course.
The facility has an exemption in place related to the bathroom doors. As part of the exemption the facility is required to inform new PIC’s and families of the situation upon intake and offer an alternate room. Please ensure that the approved letter is provided upon admission.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jul 31, 2018

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