LICENSING: 30040 - RCR s.8(2)(b) - A licensee must not make any structural change to a community care facility unless the licensee (b) receives written approval from the medical health officer.
Observation: During the walkthrough of the facility while in the backyard, the Manager stated a new portion was added to the facility approximately 2 years ago which included an addition of a bedroom.
After further review of this situation to ensure the appropriate process was followed as there is no approval of the proposed plans on Community Care Facilities Licensing's (CCFL) file nor City of Langley approvals, the Licensing Officer looked into this further:
- On November 1, 2023 the Licensing Officer asked for further information and confirmation if a 6th bedroom was added as previously CCFL was aware of proposed upgrades as a result of water damage in the kitchen and laundry rooms only.
- On November 2, 2023 the Manager e-mailed the proposed plan/health and safety plan dated September 27, 2021 that was sent to a former Licensing Officer, including floor plans.
- An e-mail from the Licensee Contact to a former Licensing Officer dated January 28, 2019 proposing to increase to 6 maximum capacity.
- On November 2, 2023 the City of Langley provided confirmation the City of Langley issued final approvals for the upgrades. The e-mail stated the following
* To enlarge the living room, adding a new bedroom, laundry room, and bathroom with roll-in shower.
Please note:
- The Licensing Officer noted the changes on November 1, 2023 and asked for further information which was provided. The current maximum capacity will remain at 5 and if the Licensee plans to increase the maximum capacity to 6 then the process need to be followed in consultation with your Licensing Officer for this. As the changes were completed and no CCFL approval or City of Langley approval were received at the time the work was completed, this is a contravention to section 8 (2)(b) of the Residential Care Regulation.
Corrective Action(s): A licensee must not make any structural changes to the community care facility unless the licensee receives written approval from the medical health officer (This is the Licensing Officer delegated by the Medical Health Officer).
Date to be Corrected: November 15, 2023.
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: There is no menu audit completed.
Corrective Action(s): Please ensure menu audits are completed on a regular basis.
Date to be Corrected: November 15, 2023.
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: A walkthrough of the facility, it was noted there are scuff marks/paint chipping off (e.g., bedroom door trims lower portion) and/or holes in the walls throughout the facility.
In addition below the kitchen sink on the right hand side cabinet door (upper / top portion) with white coloured paint that has come off.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 30, 2023.
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: There is no emergency menu in-place. On November 1, 2023 the Licensing Officer sent an e-mail to the Manager with a sample emergency menu to guide the facility in developing their own site specific emergency menu.
Corrective Action(s): Please ensure there is an emergency menu in-place.
Date to be Corrected: November 15, 2023.
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: In review of a person in care's care planning documentation there were to care plans with a date of May 2022. The Manager will ensure a current date is noted if there are no changes required to the care plans (specifics provided during the routine inspection as the care plans that didn't have current dates noted).
Corrective Action(s): Please ensure the requirements of Section 81 (4(b)(i) of the Residential Care Regulation are being met.
Date to be Corrected: November 15, 2023.
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: For example week 2 of the Spring/Winter menu for evening snack on Saturday is noed with ice cream. Please note: Ice cream overall does not provide nutritional value and the Manager will look at adding additional food groups as required to meet the intent of the Residential Care Regulation.
On the minced menu pudding is noted as a snack on Friday. The Manager clarified this is either vanilla or chocolate and an additional food group is required. In addition for Monday yoghurt is noted only. The Manager clarified that fruit is in the yoghurt and this will be documented as such.
Corrective Action(s): Please ensure that each menu provided for each day at least 2 nutritious snacks with each snack containing at least 2 food groups as described in Canada's Food Guide.
Date to be Corrected: November 15, 2023.
|