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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BKNKPH
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
December 17, 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 inspection 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 (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.
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 www.fraserhealth.ca/residentialcare for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: 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: Upon inspection of the physical facility it was noted that one PIC's (Person in Care) room had scratches on the painted wall where the laundry hamper was placed. There were paint peel off observed in the living room and dinning areas as well. The Manager informed LOs that these items were on the priority list of the maintenance team.
Corrective Action(s): Ensure that rooms and common areas are maintained in good state of repair.
Date to be Corrected: January 31st, 2020

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Upon review of the menu substitution list, LO noted that items of protein food group was substituted with another food group for one day's menu. The manager informed LOs that this was a switch between 2 different days' menus because ingredients were not available.
Corrective Action(s): Ensure that substitutions be made from the same food group and have a similar nutritional value.
Date to be Corrected:
January 31st, 2020
Comments

The Licensing Officer (LO) would like to thank the Manager and staff for their time and assistance in completing this routine inspection.

It was observed during the inspection that menu substitution list had programs such as party, special occasion, birthday listed on the substitution list. The manager has been informed by LO that a documented list of food items served during such programs must be made available at inspection if requested.

This report was reviewed and discussed with manager and senior staff. A copy of this report was left at the facility.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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
Jan 31, 2020
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.