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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B8VSAF

FACILITY NAME
Keary Street Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
2582038
FACILITY ADDRESS
313 Keary St
FACILITY PHONE
(604) 522-4032
CITY
New Westminster
POSTAL CODE
V3L 3L2
MANAGER
Angela Forcier

INSPECTION DATE
January 28, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.3
ARRIVAL
09:00 AM
DEPARTURE
02:00 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604 918 7526 or fax 604 918 7520.

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-ASGTF4 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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: A light switch in DB's room was observed to be damaged.
Corrective Action(s): Please ensure that all equipment is maintained in a good state of repair.
Date to be Corrected: Feb. 12, 2019

STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Fire Drills were observed to be missing for November and December. The house has been undergoing renovations but residents were still in place.
Corrective Action(s): Please provide a plan that will ensure that staff training for emergencies continues regularly.
Date to be Corrected: Feb. 12, 2019

POLICIES AND PROCEDURES: 33320 - RCR s.85(2)(b) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (b) the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Observation: A reference to orientation to the regulations and the Act was not found in the orientation policy at inspection.
Corrective Action(s): Please ensure there are policies to guide staff regarding orientation to the legislation.
Date to be Corrected: Feb. 12, 2019

RECORDS AND REPORTING: 39230 - RCR s.79(1)(a) - A licensee must keep a record in respect of each person in care showing the following information: (a) all money, valuables and other things held by the licensee in trust or safekeeping for persons in care.
Observation: Three financial records for residents were observed. Reconciliation information was missing for each person's record for 2-3 months.
Corrective Action(s): Please provide a plan that will ensure that correct records using generally accepted accounting principles (GAAP) are kept at all times
Date to be Corrected: Feb. 12, 2019


Comments

This facility has recently completed an extensive facelift/renovation. The staffs were very eager to assist with this inspection. The facility recently completed an Accreditation Inspection (CARF) and received a 3 year accreditation. I would like to thank the staff for their very willing assistance with this 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
Feb 12, 2019

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