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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BKWQVJ
FACILITY NAME
Decaire House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081056
FACILITY ADDRESS
498 Decaire St		FACILITY PHONE
(604) 939-6106
CITY
Coquitlam		POSTAL CODE
V3K 5A3		MANAGER
Jessica Player
INSPECTION DATE
January 17, 2020		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
12:30 PM		DEPARTURE
03:30 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 and Assisted Living Act (CCALA), the Residential Care Regulations (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.
The following areas were reviewed:
· Licensing · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this 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 and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: Restraints are used for preventative measures to ensure PIC’s safety. No PIC consents were on file.
Corrective Action(s): Please ensure that the agreement(s) for the use of restraint is signed by the PIC or the relative who is closest to and involved in the life of the person in care.
Date to be Corrected: February 14, 2020

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Upon review of 1 out of 2 PIC files, it was noted that 1 PIC file does not have written consent to call medical/nurse practitioner or ambulance in case of an accident or illness.
Corrective Action(s): Please ensure that written consent is in place for the PIC.
Date to be Corrected: February 14, 2020
Comments

The Licensing Officer (LO) would like to thank the Manager for his time and assistance in completing this routine inspection.
This report was reviewed and discussed with manager. A copy of this report was left at the facility.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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 14, 2020
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.