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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-D28P3B
FACILITY NAME
Dufferin Care Centre		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTGK
FACILITY ADDRESS
1131 Dufferin St		FACILITY PHONE
(604) 552-1166
CITY
Coquitlam		POSTAL CODE
V3B 7X5		MANAGER
Christian Buuz
INSPECTION DATE
February 07, 2024		ADDITIONAL INSP. DATE (multi-day)
February 08, 2024		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8.2
ARRIVAL
10:20 AM		DEPARTURE
04:20 PM		ARRIVAL
10:20 AM		DEPARTURE
12:45 PM		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), 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 inspections include:
· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records & 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/Regulations not met 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 -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Upon review of staffing files, 2 out of 8 files did not show evidence that screening for tuberculosis had been completed.
Corrective Action(s): A licensee must not employee a person in a community care facility unless evidence has been obtained that the person has complied with the provinces Immunization and tuberculosis control program
Date to be Corrected: February 15 2024

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Upon review of staff files, 2 out of 8 did not have performance reviews within the last three years as per the facilities polices
Corrective Action(s): A licensee must ensure that the performance reviews of each employee is reviewed regularly and as per the facility polices and procedures
Date to be Corrected: February 15 2024


Comments

Thank you to all staff for their time and assistance during this inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Feb 15, 2024
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.