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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-B7DVAF

FACILITY NAME
Alice Lake Place Group Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1003558
FACILITY ADDRESS
2724 Alice Lake Pl
FACILITY PHONE
(604) 941-4918
CITY
Coquitlam
POSTAL CODE
V3C 5W8
MANAGER
Lorraine Fraser

INSPECTION DATE
December 12, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
12:45 PM
DEPARTURE
04:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation:
During testing of the water temperature it was noted that the water temperature in the kitchen was 51.7 and in the upstairs bathroom was 51.9
Corrective Action(s): Ensure water temperature is below 49.0 degrees ( temperature gauge was adjusted during inspection)
Date to be Corrected: corrected

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Upon inspection of the downstairs bedroom it was noted that there were a number of electrical cords and gaming equipment cords unsecured and were a possible tripping hazard
Corrective Action(s): Ensure all electrical cords are secured in a safe manner
Date to be Corrected: Dec 19, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31830 - RCR s.36(2) - If necessary to protect the health or safety of persons in care, a licensee must ensure that the outside activity area is secured by a fence or other means.
Observation: The outside yard backs on to a large forested ravine that has public trails. This area is accessible to the PIC's and in turn the public have access to the PIC's yard. This area is well know to have wild animals in it and the facility has had a number of bear sightings.
Corrective Action(s): Ensure that the outside activity area is secured by a fence or other means to protect the safety of the persons in care
Date to be Corrected: March 20, 2019

STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Upon review of 3 staff files it was noted that 2 files did not have evidence of compliance with the provinces TB control program
Corrective Action(s): Ensure all staff have evidence of compliance with the provinces TB control program
Date to be Corrected: Jan 2, 2018

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: During inspection it was noted that a bag of sugar and a bag of flour were open and unlabled
Corrective Action(s): Ensure food is safely stored
Date to be Corrected: Dec 19, 2018


Comments

There is a substitution list available and is being used although there appeared to be a number of gaps. Please ensure that the substitution list is used consistently for menu substitutions

The 2 couches upstairs in the living room need to be replaced, although they are clean they are well used and showing signs of damage to springs and have sinking cushions

It is recommended that the facility create a bear sighting protocol/guidelines to add the emergency procedures and to be practiced with the PIC's

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
Dec 26, 2018

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