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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

JKAS-CR8LKL

FACILITY NAME Cook Avenue		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081755
FACILITY ADDRESS 21181 Cook Ave			FACILITY PHONE (604) 466-8218
CITY Maple Ridge	POSTAL CODE V2X 7P7		MANAGER Marnie Govereau

INSPECTION DATE April 25, 2023	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3
ARRIVAL 10:00 AM	DEPARTURE 01:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 6

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 as part of a routine inspection:
- Licensing
- Physical Facility
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this routine inspection, a facility risk assessment tool is completed. The risk assessment includes contraventions 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/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

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): Physical inspection of the upstairs main bathroom found 2 different spray bottles of cleaning agents hanging on the shower curtain rod.
Corrective Action(s): Please ensure to have secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected:

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: Review of 2 Persons in Care(PIC) Charts determined that 1 PICs chart did not have evidence of 4 monthly weights and the other PICs chart did not have evidence of 5 monthly weights over the last 12 months.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: May 9, 2023

Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance completing this routine inspection.

HR/Staffing will be reviewed with HR Manager at RMACL Head Office, if unable to send details.

Please provide a written response by May 9, 2023 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was reviewed with the staff on site and signed. It was then sent with the corresponding risk assessment to the Manager/ Licensee via email.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date May 09, 2023

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