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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JBAY-C2FN9H
FACILITY NAME
Cochrane House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1003546
FACILITY ADDRESS
567 Cochrane Ave		FACILITY PHONE
(604) 931-5148
CITY
Coquitlam		POSTAL CODE
V3J 2A3		MANAGER
Michelle McCormick
INSPECTION DATE
April 23, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:30 AM		DEPARTURE
01:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
5
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
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
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: An inspection of bedroom furniture for persons in care found that one dresser had a broken handle and multiple loose handles that require repair.
Corrective Action(s): Ensure that all furniture for use by persons in care are maintained in a good state of repair.
Date to be Corrected: May 10, 2021

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: An inspection of the physical facility found the following:
1) There was a tarp on the roof of the facility to prevent leakage as a result of a vent that was damaged during a storm that occurred in January 2021 that requires repair.
2) There was a fluorescent light in the emergency supply room that was observed to be not working properly as it was only providing dim lighting.
Corrective Action(s): Ensure that all rooms and common areas are maintained in good state of repair.
Date to be Corrected: May 21, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: An inspection of the physical facility found that in the backyard there was debris from a gazebo that had been destroyed as a result of a storm that occurred in January 2021 that requires removal.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: May 14, 2021

POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: A review of the facility's emergency supplies found that the supply of water was insufficient to support persons in care and staff for 3 days.
Corrective Action(s): Ensure that an emergency plan prepares for and is able to respond and recover from any emergency including procedures for the evacuation of persons in care.
Date to be Corrected: May 10, 2021
Comments

Licensing officer completed a COVID-19 Prevention Checklist with the site and provided the facility with a blank copy of the checklist to support the facility's COVID-19 readiness. The completed checklist was placed on the facility's physical file.

Please submit a written response by May 10, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

This inspection report was not signed by management as it was reviewed with the management over the telephone and sent via email to the site to reduce the amount of time the licensing officer had to spend on site as per COVID-19 prevention measures.
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
May 10, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.