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

FACILITY NAME
Thornton
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
TDAH-82LV3P
FACILITY ADDRESS
11960 249A St
FACILITY PHONE
(604) 463-5188
CITY
Maple Ridge
POSTAL CODE
V4R 2E3
MANAGER
Robert Hicks

INSPECTION DATE
October 18, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:15 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

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: 31200 - RCR s.19(3) - If a licensee installs electronic devices for the purposes of transmitting or recording images of persons in care or members of the public, the licensee must display in a prominent place notice that electronic surveillance is being used.
Observation: The facility was observed to be using an electronic device for the purposes of transmitting images of persons in care; however, no notice was observed to be prominently displayed explaining that electronic surveillance is being used.
Corrective Action(s): Ensure that notice is displayed in a prominent place explaining that electronic surveillance is being used at the facility.
Date to be Corrected: November 18, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): 3 regular medications belonging to a PIC was found in a shared washroom located on the ground floor.
Corrective Action(s): Ensure that all medications in the facility are safely and securely stored.
Date to be Corrected: November 18, 2022

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: Review of their medication cabinet found three PRN medications passed the expiry date.
Corrective Action(s): Ensure expired medications are returned to the pharmacy when the date on the medication has passed.
Date to be Corrected: November 18, 2022

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 1 of 4 PIC's weight charts determined that a weight was not captured for the month of September 2022 and there was no documentation provided to explain why the weight was missing. This is a repeat contravention.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: November 18, 2022


Comments

I would like to thank the team at Thornton House for their time and assistance in the completing this inspection. Please submit a written response by November 18, 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 18, 2022

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