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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CJPU2Q
FACILITY NAME
Decaire House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081056
FACILITY ADDRESS
498 Decaire St		FACILITY PHONE
(604) 939-6106
CITY
Coquitlam		POSTAL CODE
V3K 5A3		MANAGER
Jessica Player
INSPECTION DATE
September 28, 2022		ADDITIONAL INSP. DATE (multi-day)
October 14, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
01:00 PM		DEPARTURE
03:30 PM		ARRIVAL
01:15 PM		DEPARTURE
02:15 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). 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 for Additional resources and Links to the Legislation (CCALA & RCR) Residential Care Regulation Community Care and Assisted Living Act

Contraventions
Previous Inspection -
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: PRN medication results were not recorded for 3 persons in care.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: October 31, 2022

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: One of 4 persons in care (PIC) did not have the weight taken for the month of May, June and September 2022. As per staff the PIC was in transition from home to facility, staying only for few days in the facility in those months.
Corrective Action(s): Please ensure that person in care is weighed at least once each month.
Date to be Corrected: October 31, 2022
Comments

Thank you to all the staff for their assistance and cooperation with the completion of this routine inspection.
The findings were discussed with the facility leadership while the licensing officer was on site. The copy of the report and risk assessment were provided via email.

Please submit a written response to this routine inspection to Licensing by October 31, 2022.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Oct 31, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.