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

JSTT-CYJM6M

FACILITY NAME 122nd Avenue Home		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081369
FACILITY ADDRESS 22229 122nd Ave			FACILITY PHONE (604) 467-8828
CITY Maple Ridge	POSTAL CODE V2X 3X8		MANAGER Angaline Madhavan

INSPECTION DATE December 15, 2023	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3
ARRIVAL 10:50 AM	DEPARTURE 01:50 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed 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 (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. Care systems reviewed during inspections include: · Licensing · Physical Facility · Staffing · Policies and Procedures · Care and Supervision · Hygiene and Communicable Disease Control · Medication · Nutrition and Food Services · Program · Records & 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 -

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

CARE AND/OR SUPERVISION: 34620 - RCR s.81(3)(a)(iii) - A care plan must include all of the following: (a) a plan to address (iii) if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment. Observation: Bed rails were observed in all four of the PIC's bedrooms, and confirmed to be used for all four PIC's in care. Upon review of the care plans, it was documented they were required for safety, however two PICs files did not have consent. Corrective Action(s): A care plan must include an agreement to use restraints when restraints are being used. Date to be Corrected: December 29 2023

Comments

Upon review of the menu two person's in care (PIC) had water recorded as their snack option, It was confirmed there is a diet plan in place and more detailed documentation will be provided. . Thank you to staff for their assistance during this inspection

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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