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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

NBIH-BL9R7D

FACILITY NAME Cook Avenue		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081755
FACILITY ADDRESS 21181 Cook Ave			FACILITY PHONE (604) 466-8218
CITY Maple Ridge	POSTAL CODE V2X 7P7		MANAGER Rhona Riggins

INSPECTION DATE January 27, 2020	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2.5
ARRIVAL 02:00 PM	DEPARTURE 04:30 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 5

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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo

Contraventions

Previous Inspection - Contraventions observed on FIR #NBIH-AUTRQJ have been corrected.

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan. Observation: Licensing reviewed 3 PIC's binders and found that 1 PIC's care plan and oral hygiene guide had not been reviewed since July 2017. Corrective Action(s): Please ensure that each care plan is reviewed at least once each year. The manager stated that appointments have been made with the PIC's doctors to review all the care plans during the second week of February 2020. Date to be Corrected: February 28 2020

Comments

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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