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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KTRR-C3FNNJ

FACILITY NAME
Como Lake House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081662
FACILITY ADDRESS
1433 Como Lake Ave
FACILITY PHONE
(604) 931-3272
CITY
Coquitlam
POSTAL CODE
V3J 3P5
MANAGER
Wendy Shim

INSPECTION DATE
May 28, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.75
ARRIVAL
10:00 AM
DEPARTURE
02:45 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 Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSOP). 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
· Programming
· 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 :http://www.gov.bc.ca/residentialcarefacility
· 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: A container of dolomite lime was observed on a counter in the kitchen.
Corrective Action(s): Ensure chemical products and other hazardous materials are stored in a safe and secure storage area.
Date to be Corrected: Corrected at time of inspection.

STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: 16 employee file records were reviewed. The criminal record check for 1 of 16 employees was expired and results of a new criminal record check have not been submitted.
Corrective Action(s): Ensure a record of valid criminal record checks obtained through the Ministry for Public Safety & Solicitor General are on file
for employees prior to expiry and that criminal record checks are completed prior to commencing employment.
Date to be Corrected: Health and Safety Plan addressing this contravention to be submitted to geographic LO by June 4, 2021.

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: (REPEAT CONTRAVENTION) 1 commode in the tub room was not labelled so as to identify the PIC. A second commode in the tub room was labelled; however, the label was faded, peeling, and the PIC name was illegible.
Corrective Action(s): Ensure personal hygiene items and equipment are labelled so as to identify PIC.
Date to be Corrected: June 7, 2021


Comments

Community Care Facilities Licensing (CCFL) would like to thank staff and management for their time and assistance in completing this routine inspection.
Upon review of the menus and menu audits, it was observed that the number of items on some days did not align with the number recorded on the corresponding menu audit sheet; however, the menus did meet the minimum servings requirements for all food groups. Staff indicated that they are planning to review and revise the rotational menus and corresponding menu audits.
Staff indicated that the plan to replace/repair windows in the kitchen and one PIC's bedroom as per the previous inspection on December 3, 2019 were put on hold by BC Housing. A work order has been submitted and BC Housing indicated to facility staff that repairs will be completed during summer 2021.
A COVID-19 screening was completed at the facility prior to commencing the inspection. Additionally, a COVID-19 Prevention Checklist was completed and a blank copy was provided to the facility as a resource tool.
In order to minimize time spent on site due to the COVID-19 pandemic, this report was reviewed with facility management via phone conference and a copy emailed to management.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jun 07, 2021

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