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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
LBUL-C7GQ2N

FACILITY NAME
Graceland Gates
SERVICE TYPES
140 Community Living
150 Acquired Injury
FACILITY LICENSE #
NNAL-8N3MVT
FACILITY ADDRESS
6587 238th St
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Deidra Vanderlee

INSPECTION DATE
July 30, 2021
ADDITIONAL INSP. DATE (multi-day)
September 10, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:00 AM
DEPARTURE
10:30 AM
ARRIVAL
10:00 AM
DEPARTURE
12:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

This follow-up to routine inspection was conducted in accordance with the Community Care and Assisted Living Act (CCALA) and Residential Care Regulation (RCR).  
 
The purpose of this inspection was to determine if contraventions identified during Routine Inspection CRAU-BYXPJX (date, 5-Mar-2021) had been corrected. Licensing had received a written response to the contraventions identified during the routine inspection on March 5, 2021.  

Day 1 of this follow-up inspection was unscheduled and took place on July 30, 2021. As this inspection could not be completed on this date, Day 2 was schedule and occurred on September 10, 2021. 

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: Cleaning chemicals were stored under a kitchen sink in an unsecured cabinet and unsecured storage/laundry room. One or more of the persons in care completed laundry and other tasks using these cleaning chemicals. However, these cleaning products were accessible to persons in care during times when staff were unable to maintain ongoing monitoring (line-of-site) of them.   
Corrective Action(s): Please ensure that cleaning products and other chemicals are secured and inaccessible to persons in care during times when monitoring of their use cannot be maintained.  
Date to be Corrected: October 4, 2021

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: A swimming pool was located on the premise and it was surrounded by a fence; however, this fence was not secured, as 1 entry point locking mechanism was not engaged and 1 entry point gate was fully open. 
Corrective Action(s): Please ensure that the swimming pool is not accessible to persons in care during times when continuous supervision cannot be maintained. Licensing was informed that this concern has already be addressed and this area will be secured as required.  
Date to be Corrected: October 4, 2021

STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Two staff did not have a non-expired Criminal Record Check (CRC).  CRC applications had been submitted on August 26, 2021 and the CRC confirmation letter had not been received. New employees must have a non-expired CRC prior to working with persons in care. Existing employees must have a new CRC or evidence of a CRC application sent to the CRC registrar prior to expiry.  It was determined during a routine inspection conducted on March 5, 2021 that one or more staff did not have CRC in good standing. Licensee had provided a written response on March 19, 2021 that an application would be submitted. It is the responsibility of the Licensee to ensure the submission of the CRC application for existing employees prior to expiry.  Therefore, this contravention initially identified during Routine Inspection has not been addressed. 
Corrective Action(s): Please immediately correct this contravention and ensure that all staff have a non-expired CRC from the CRC Registrar. Provide a written response by October 22, 2021 on how you addressed this contravention and how you will ensure that CRCs will be obtained in the future for all new staff prior to working with persons in care and a CRC or a CRC application has been submitted prior to expiry for all existing staff.  
Date to be Corrected: October 4, 2021

STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: One staff did not have a valid first aid/CPR certification and, at times, this staff worked alone with person in care; as a result, persons in care sometimes did not have immediate access to an employee with a valid first aid/CPR.
Corrective Action(s): Please ensure that persons in care have immediate access to an employee with a valid first aid/CPR certification.  
Date to be Corrected: October 4, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Three 4-6kg packages of ground beef were stacked on top of each other above a refrigerator’s vegetable drawer. There was no plate or other means of preventing liquids from the meat to drip down onto other food items. The refrigerator was located in a garage.   
Corrective Action(s): Please ensure that foods, such as ground beef, are stored in a manner where they cannot potentially cross-contaminant other foods.  
Date to be Corrected: October 4, 2021


Comments

The facility (home) had 5 bedrooms and it was licensed for a maximum of 6 persons. One bedroom was being used for double occupancy. Section 25(1) Residential Care Regulation requires that each person in care has their own separate bedroom. The exemption process was discussed and a blank exemption form was provided to the Licensee’s representative.  
 
It was discussed with the Licensee that a completed risk assessment provides the minimum number of inspections that must be conducted per year; however, additional inspections may be conducted and these inspections may be unscheduled or scheduled.   
 
Please provide a written response to this inspection by September 30, 2021. The response should include the actions that will be taken to address the contraventions outlined in this report.  

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
Oct 22, 2021

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