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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

CJOS-B6HLYD

FACILITY NAME Rosedale		SERVICE TYPES 125 Substance Use	FACILITY LICENSE # LBJE-6HXRCG
FACILITY ADDRESS Removed at operator's request			FACILITY PHONE Removed at operator's request
CITY Chilliwack	POSTAL CODE Removed at operator's request		MANAGER Removed at operator's request

INSPECTION DATE November 13, 2018	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 8
ARRIVAL 09:30 AM	DEPARTURE 02:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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. Care systems reviewed include the following: Licensing Physical Facility Staffing Policies and Procedures Care and Supervision Hygiene and Communicable Disease Control Medication Nutrition and Food Services Program Records & Reporting Resident Bill of Rights Additional CCALA Sections 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).

Contraventions

Previous Inspection - Contraventions observed on FIR #WCLK-APNLFE have been corrected.

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

Observed Violations

LICENSING: 30060 - RCR s 8(3)(b) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (b) replace the manager, either by hiring a person who, or using a hiring process that, is approved in writing by the medical health officer. Observation: Discussion with the manager indicates she has been in this role for approximately three months. Licensing has not received an application to amend the license. Corrective Action(s): Submit an application to amend the license and obtain written approval from the medical health officer. Date to be Corrected: 23 Nov 2018 PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition. Observation: One of three bedrooms inspected was found to be in an untidy state. Numerous clothing and personal items were on the floor and as such it was not in a clean condition. Discussion with the Manager indicates that all bedrooms are inspected for cleanliness once per week and this room was clean for that inspection, however this person in care has not maintained the room in a clean condition. Corrective Action(s): Ensure room is maintained in a safe and clean condition. Date to be Corrected: 18 Nov 2018 MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record. Observation: One of four medication administration records (MAR) observed found that one medication was not listed on this record. Discussion with the Manager about this indicates that although this medication was in a blister pack , it was not on the MAR because it was brought to this facility by the person in care from a previous facility. This medication is a PRN medication and has not been administered since this person in care has been at this facility. Corrective Action(s): Ensure that the pharmacist records all medications on the person in care's MAR. Date to be Corrected: This was corrected during the inspection. The pharmacist faxed an updated copy of the MAR to the facility.

Comments

This LO would like to thank the Manager and staff at this facility for their assistance in completing this inspection.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Nov 23, 2018

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