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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CKJSGY

FACILITY NAME
Cedarvale (East)
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081798
FACILITY ADDRESS
23635 118th Ave
FACILITY PHONE
(604) 467-7509
CITY
Maple Ridge
POSTAL CODE
V4R 2C9
MANAGER
Debbie Middleton

INSPECTION DATE
October 25, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
12:00 PM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

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/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: 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: The wall located near the kitchen had 2 areas of paint chipped measuring approximately 2" in length exposing the inner wall, one of which was covered by duct tape.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 25, 2022

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 2 of 3 PIC's health care records did not have consent to receive medical treatment.
Corrective Action(s): Ensure that consent in writing from the person in care (PIC) or parent or representative of the PIC to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Date to be Corrected: November 25, 2022


Comments

Licensing observed the fire extinguisher had an expiry date of October 13, 2022. The facility manager stated the inspection was booked for October 25, 2022 but had cancelled. The facility manager stated they would alert the person in their agency to have the fire inspection rescheduled.

I would like to thank the team at Cedarvale for their time and assistance in the completing this inspection. Please submit a written response by November 25, 2022 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
This inspection report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Nov 25, 2022

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