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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JFUR-CZRSWN

FACILITY NAME
Baillie House
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962KWT
FACILITY ADDRESS
11762 Laity St
FACILITY PHONE
(604) 476-7888
CITY
Maple Ridge
POSTAL CODE
V2X 7G5
MANAGER
Jason Faulkner

INSPECTION DATE
January 23, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
10:00 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
148

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
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A review of 2 PICs medication and administration record (MAR) found 12 of 19, and 6 of 7 PRN effectiveness information not documented.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: 6-Feb-2024


Comments

Thank you for your time and assistance with completing this inspection.

Please submit a written response by February 6, 2024 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

(Please note: this inspection report was reviewed with the Manager, written on-site and forwarded via email.)

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Feb 06, 2024

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