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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME Bayshore Home		SERVICE TYPES 140 Community Living	FACILITY LICENSE # ROLE-8VMNVH
FACILITY ADDRESS 44419 Bayshore Ave			FACILITY PHONE (604) 824-5955
CITY Chilliwack	POSTAL CODE V2R 0A5		MANAGER Katrina Berarducci

INSPECTION DATE July 21, 2016	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3
ARRIVAL 10:00 AM	DEPARTURE 01:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s (LO) observations, review of facility records and information provided by facility staff at the time of the inspection. As part of the Routine Inspection a 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. A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights. Visit CCFL website at www.fraserhealth.ca/ccfl for additional resources and links to legislation (CCALA and RCR)

Contraventions

Previous Inspection - Not Applicable

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed. Observation (CORRECTED DURING INSPECTION): A random audit of 2 person in care's medication storage bins was completed and one expired medicated topical cream, dated June 2016, was found in one bin. Corrective Action(s): The Manager removed the expired medication immediately. There is a system in place and written procedures for staff to follow for monthly reconciliation of medications. Date to be Corrected: July 21, 2016

Comments

Physical Facility Renovations to the kitchen and lower level bathroom have been completed and the previously accepted Health & Safety Plans are no longer required. As the contravention documented in this report was addressed during the inspection, no further action or response is required. This inspection was conducted with the support of the facility Manager copies of the inspection report and the Risk Assessment Tool were reviewed, discussed, and provided to her.

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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