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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AT72C6
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
November 16, 2017		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.75
ARRIVAL
01:30 PM		DEPARTURE
05:30 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 7710
Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-AG9V9B have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
LICENSING: 30140 - CCALA s.7(1)(c) - A licensee must do all of the following: (c) display the licence in the prescribed manner.
Observation: License not displayed, outdated manager identified on license.
Corrective Action(s): Please post license in prescribed manner, licensing will provide updated license.
Date to be Corrected: Dec 15, 2017

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: Current criminal record check (CRC) was absent from 1 staff file
Corrective Action(s): Please provide a plan that will ensure that each employee has current CRC.
Date to be Corrected: Dec. 15, 2017

STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Evidence of fire drills was not present for January, April and May.
Corrective Action(s): Please provide a plan that will ensure that training occurs at recommended intervals.
Date to be Corrected: Dec. 15, 2017

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Freezer temperature were too warm in each fridge.
Corrective Action(s): Please provide a plan that will ensure that the temperature is monitored and maintained within the recommended span of -18 to -22 degrees Celsius.
Date to be Corrected: Dec. 15, 2017

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Prescription mineral oil found in medication cupboard dated 2015.
Corrective Action(s): Please provide a plan that will ensure that all medications are within their expiry period.
Date to be Corrected: Dec. 15, 2017
Comments

The requirement for 'height and weight on admission' for PIC's was not consistent between each PIC's documents. Please provide a plan that will identify the height and weight on admission in a manner that will retain the documentation into the future.
The fire escape planning diagram was out of date. Please provide a plan to update the fire escape diagram and notify licensing by Dec. 15, 2017.
One staff was found to have no record of Food Safe Training. The manager was provided with the "Caring About Food Safe" information. This LO will confirm with the Licensing Dietitian about the expiry time for this training.
This house is clean and well organized. The staff were seen to relate in a very warm and comfortable manner with the PIC's. The PICs were seen to respond in a very friendly, often joking way with the staff in return.
Thank you to staff and residents who participated in this inspection.
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
Nov 16, 2017
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Click here for a description of each "Category" of violation displayed.