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
AROE-BB2QW6

FACILITY NAME
KinVillage
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0980021
FACILITY ADDRESS
5410 10th Ave
FACILITY PHONE
(604) 943-0155
CITY
Delta
POSTAL CODE
V4M 3X8
MANAGER
Cynthia Langenberg

INSPECTION DATE
April 03, 2019
ADDITIONAL INSP. DATE (multi-day)
April 08, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
11:00 AM
DEPARTURE
01:00 PM
ARRIVAL
10:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
Physical Facility
Staffing
Polices & Procedures
Care & Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records and 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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: 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: it was noted during inspection that
* The staff washroom on floor AB has damaged flooring
* The tub brushes and mops are left on the floor in the tub rooms
* There was a broken commode and damaged wood desk in the tub room to be disposed of
* The wall corners in the dining area are damaged and missing paint
* Lifts are stored in the hallway along the hand rail on first floor
Corrective Action(s): Ensure all common areas and rooms are maintained in safe and clean condition
Date to be Corrected: May 17 2019

HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: 1 of 7 staff files reviewed showed no evidence of a TB record
Corrective Action(s): Ensure all staff are in compliance with the Tuberculosis program
Date to be Corrected: April 22,2019

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: During inspection of the physical facility it was noted that in 4 of 6 rooms and 2 tub rooms there were unlabeled barrier creams
Corrective Action(s): Ensure all items used for personal care and personal use by the PIC's is labeled with their name
Date to be Corrected: May 17, 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: It was noted that food used for the morning snack was being stored on top of the fridge
Corrective Action(s): Ensure food is safely stored
Date to be Corrected: April 22, 2019


Comments

During the inspection of the facility it was noted that some of the rooms curtains did not close in the washroom area completely. It was discussed that the facility would provide a solution to ensure complete privacy in those specific rooms.

Although there is a complaint policy and procedure in place it is recommended that the facility post their complaint forms in a public area for families, PIC's and community to access if needed

Thank you to the staff and management at Kin Village for their support with the routine 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
Apr 22, 2019

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