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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBOI-BAQLXV

FACILITY NAME
Fleet Street Group Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
LBAA-8CFSTG
FACILITY ADDRESS
2994 Fleet St
FACILITY PHONE
(604) 944-0408
CITY
Coquitlam
POSTAL CODE
V3C 3R8
MANAGER
Luis de Sousa

INSPECTION DATE
March 28, 2019
ADDITIONAL INSP. DATE (multi-day)
March 29, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
02:30 PM
DEPARTURE
04:30 PM
ARRIVAL
10:30 AM
DEPARTURE
12:00 PM
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. A second day was added to the inspection so that the manager could be available to access staff files.
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 -
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: On inspection the LO noted:
- upstairs bathroom vanity showing wear, paint chipped off approx 40% of surface
- upstairs bedroom windowsill paint chipped off approx 20% of surface
- upstairs bedroom closet door off (site already has plans to replace)
- a kitchen table is outside in the back yard waiting for disposal
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: July 15, 2019

POLICIES AND PROCEDURES: 33130 - RCR s.68(3)(a) - The medication safety and advisory committee must establish and review as required (a) training and orientation programs for employees who store, handle or administer medications to persons in care.
Observation: MSAC minutes were available for review and committee meets regularly. Evidence of a training program is in place, but MSAC does not currently review.
Corrective Action(s): Ensure that the MSAC meets all of the requirements outlined in RCR 68
Date to be Corrected: September 15, 2019


Comments

Thank you to the staff and manager at Fleet St. for their assistance at the inspection.

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
Apr 12, 2019

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