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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-AQRRNY

FACILITY NAME
Campbell House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
TDAH-7Z8QHB
FACILITY ADDRESS
21351 Campbell Ave
FACILITY PHONE
(604) 463-7101
CITY
Maple Ridge
POSTAL CODE
V2X 7G6
MANAGER
Kim Rilka

INSPECTION DATE
August 31, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
09:30 AM
DEPARTURE
02:00 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604-949-7714 or by email at nicholas.birch@fraserhealth.ca

Contraventions
Previous Inspection - Contraventions observed on FIR #SCLY-ADLSPK 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: 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: During a review of the physical facility, the following was noted:
- The garden had lots of weeds growing throughout.
- Disused items were stored throughout the garden, some rusting and rotting.
- The garden shed was rotting and leaning to one side.
- The basketball net at the front of the house was ripped and torn.
Corrective Action(s): Please ensure the common areas of the facility are kept in a good state of repair and that there is a system in place for maintaining this.
Date to be Corrected: September 30 2017

CARE AND/OR SUPERVISION: 34790 - RCR s.83(1)(a) - A licensee of a community care facility with 24 or fewer persons in care must (a) develop a nutrition plan for each person in care.
Observation (CORRECTED DURING INSPECTION): A review of 3 PIC's care plans found 1 PIC did not have a nutritional care plan on file. The facility manager was able to create one during the inspection using the following information:
- Satisfaction Survey.
- Food and Nutrition Information and Screening form.
This information was sufficient in determining that no dietician referral was necessary at this time and no issues regarding nutrition were identified.
Corrective Action(s): Please ensure that a nutrition plan is developed for all PIC's.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34810 - RCR s.83(1)(b)(ii) - A licensee of a community care facility with 24 or fewer persons in care must (b) if a nutrition plan is developed without the assistance of a dietitian, ensure that reasonable steps are taken to assess the specific nutritional needs of the person in care who is the subject of the nutrition plan, including considering whether the person in care is at risk of being inadequately nourished because of (ii) a history of issues that affect eating by the person in care.
Observation: During a review of 3 PIC's care plans, the following was noted:
- 1 PIC had no food and nutrition information and dietician screening form on file.
- 1 PIC had no dietician screening form on file.
Corrective Action(s): Please ensure that reasonable steps are taken to assess the nutritional needs of each PIC during the development of the nutritional care plans.
Date to be Corrected: September 30 2017

PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: One PIC has no record of preferred activities or a plan of activities on file.
Corrective Action(s): Please ensure that there is an ongoing planned program of recreational activities suitable to the needs of the PIC's on file.
Date to be Corrected: September 30 2017


Comments


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