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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BHNSJZ

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
Annette Fadera

INSPECTION DATE
November 06, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine 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 (DLSP). 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 https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XXbB7myos2w for:
· Additional resources, and
· Links to the Legislation (CCALA and 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
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of medication administration record (MAR) it was observed to be missing 2 signatures and record of effectiveness for PRN medications given.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: November 08, 2019.

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of the fridge/freezer in the kitchen found that there was not a thermometer in the fridge area to monitor the temperature. It was also observed in the deep freezer that a thermometer was not in place to measure the temperature. Of concern is the temperatures are not monitored to ensure the safe storage of food.
Corrective Action(s): Ensure that all food is safely stored.
Date to be Corrected: November 15, 2019.

RECORDS AND REPORTING: 39570 - RCR s.90(1) - A licensee must maintain separate financial records for each community care facility, made in accordance with generally accepted accounting practices.
Observation: Financial records are reconciled on a monthly basis, however this had not been completed for the month of October for 1 person in care's (PIC) record.
Corrective Action(s): Ensure that all financial records are updated monthly as per the facility standard.
Date to be Corrected: November 15, 2019


Comments

Thank you to the staff at Keary Street Home for their 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
Nov 15, 2019

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