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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-BBWQEW

FACILITY NAME
Evergreen House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
LBAA-8VPVD3
FACILITY ADDRESS
638 Kemsley Ave
FACILITY PHONE
(604) 931-0974
CITY
Coquitlam
POSTAL CODE
V3J 3Z3
MANAGER
Anne Bennett

INSPECTION DATE
May 06, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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: 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: 2 cleaning solutions were stored under the kitchen sink unsecured
Corrective Action(s): ensure all cleaning solutions are stored in a safe and secure area
Date to be Corrected: corrected during inspection

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 new deck area was poured to accommodate more usable space for the wheel chairs but has not yet been fenced an there is a significant drop off on the west side that would be a safety risk if a PIC was to be outside unattended.
Corrective Action(s): Ensure all outdoor activity areas are secured and fenced for safety
Date to be Corrected: BC housing to provide date of repair

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: 1 Peri care solution was being used for all persons hygiene routines
Corrective Action(s): ensure all PIC's have their own labeled hygiene products
Date to be Corrected: Corrected during inspection

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: 2 of 4 PIC records showed that weights were not recorded in February 2019
Corrective Action(s): ensure monthly weights are completed and recorded
Date to be Corrected: May 20 2019


Comments

Through conversation with the manager it was noted that the previous contravention for the kitchen cabinet door pull areas being worn will be addressed by BC housing this Fiscal and kitchen cabinets to be re-placed

A solution has not been determined for the fencing issue noted in the previous inspection as the city, BC housing and the facility are involved in discussion as to how to address the issue and where funding will come from to address it. Privacy film will be added to the window of the PIC whose window directly looks out on to the unfenced area.

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
May 20, 2019

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