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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JBAY-C2ATCV

FACILITY NAME
Quadling House B
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
AKLN-6AGPWH
FACILITY ADDRESS
B - 820 Quadling Ave
FACILITY PHONE
(604) 931-3673
CITY
Coquitlam
POSTAL CODE
V3K 2A4
MANAGER
Lily Marian

INSPECTION DATE
April 21, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:30 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), 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 during inspections include:
Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & 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 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: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: An inspection of all bedrooms for persons in care found that none were equipped with a safe and secure place in which persons in care may store valuable property.
Corrective Action(s): Ensure that, at no cost to persons in care, bedroom furnishings include a safe and secure place in which persons in care may store valuable property.
Date to be Corrected: May 19, 2021

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: A review of facility staff files found no evidence of an annual performance review as per agency policy for one employee since March 2019.
Corrective Action(s): Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Date to be Corrected: May 19, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A review of facility staff files found that two staff did not have evidence of TB status.
Corrective Action(s): Ensure that persons employed in a community care facility provide evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 26, 2021

MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation: In the care plan of one person in care there was a plan for self-administration of medications; however, for one of the medications that is self-administered, there was no evidence available that self-administration had been approved by a medical practitioner or nurse practitioner who prescribed or ordered the medication.
Corrective Action(s): Ensure that self-administration of medications is approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Date to be Corrected: April 26, 2021


Comments

Licensing officer completed a COVID-19 Prevention Checklist with the site and provided the facility with a blank copy of the checklist to support the facility's COVID-19 readiness. The completed checklist was placed on the facility's physical file.

Please submit a written response by May 05, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

This inspection report was not signed by management as it was reviewed with the management over the telephone and sent via email to the site to reduce the amount of time the licensing officer had to spend on site as per COVID-19 prevention measures.

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 05, 2021

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