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
AKUR-BM5SNN

FACILITY NAME
Arborwynd
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081392
FACILITY ADDRESS
27136 112th Ave
FACILITY PHONE
(604) 462-0968
CITY
Maple Ridge
POSTAL CODE
V2W 1P8
MANAGER
Donald Vaughn MacPherson

INSPECTION DATE
February 25, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
12:30 PM
DEPARTURE
03:00 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 & 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
Links to the Legislation (CCALA & 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
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: Upon the review of Medication administration Records it was found that the blood sugar test was not done and not documented for a PIC this month.
Corrective Action(s): Please ensure that employees comply with the policies of the MSAC committee.
Date to be Corrected: March 13th, 2020

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Upon review of all PICs' files it was noted that there was no current consent to care form available.
Corrective Action(s): Please ensure that current consent to care forms are signed and dated is in PIC files.
Date to be Corrected: March 13th, 2020

RECORDS AND REPORTING: 39620 - RCR s.91(2)(c) - In respect of a record referred to in this regulation, a licensee must (c) produce records, on demand, to the medical health officer.
Observation: LO was unable to determine if food is stored at appropriate temperature in freezer and fridge as no record was available.
Corrective Action(s): Please ensure that temperature records are maintained for all the fridge and freezer that can be produced upon request at inspections.
Date to be Corrected: March 13th, 2020


Comments

The Licensing Officer (LO) would like to thank the Manager for his time and assistance in completing this routine inspection. The 2 PICs financial record books could not be reviewed by LO as the Manager on site didn't have the keys for the locked Safe. The LO was informed that the Director of Residential services did a routine internal audit of the financial books last week. The facility's internal finance books and petty cash system were available for review.
This report was reviewed and discussed with manager. 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 complianceNo action required

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