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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BY2S29
FACILITY NAME
122nd Avenue Home		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081369
FACILITY ADDRESS
22229 122nd Ave		FACILITY PHONE
(604) 467-8828
CITY
Maple Ridge		POSTAL CODE
V2X 3X8		MANAGER
Angaline Madhavan
INSPECTION DATE
February 08, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
11:00 AM		DEPARTURE
02:00 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 and Assisted Living Act (CCALA), the Residential Care Regulations (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.
The following areas were reviewed:
· Licensing · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this 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 and 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
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: 1/3 PIC file review noted that agreement document for use of restraint was not in place.
Corrective Action(s): Please ensure that the use of restraint agreement document is received in writing from PIC or representative of PIC.
Date to be Corrected: Mar 31, 2021.

POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Review of 2 Persons in Care (PICs) files online found that the restraint documents were not in place.
Corrective Action(s): Ensure that PIC’s with a need for on-going restraint must have the agreement signed by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: Feb 26, 2021

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: Inspection of the tub room determined that 2 personal body lotion and shampoo were being left in the tub room.
Corrective Action(s): Ensure that personal toiletries are labelled and separated with individual PIC's names and stored appropriately.

Date to be Corrected: Feb 26, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: During the physical facility inspection it was noted by Licensing that food and supplies were stored on the floor in the emergency supplies cupboard.
Corrective Action(s): Please ensure that all items are handled and stored safely off the floor.
Date to be Corrected: Feb 26, 2021
Comments

The Licensing Officer (LO) would like to thank the House Manager for her time and assistance in completing this routine inspection. Arcus Nurse was on site as well to follow through and provide support. It was brought to Licensing attention that MSAC meetings were not conducted due to the pandemic in 2020. This year facility is looking into having a virtual MSAC meeting.
This report was reviewed and discussed with manager. A copy of this report was left at the facility.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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
Mar 01, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.