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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-C6MUA4

FACILITY NAME
The Classic Homestead - West
SERVICE TYPES
150 Acquired Injury
FACILITY LICENSE #
0982780
FACILITY ADDRESS
20433 73A Ave
FACILITY PHONE
(604) 723-0497
CITY
Langley
POSTAL CODE
V2Y 1V1
MANAGER
Connie Stover

INSPECTION DATE
September 07, 2021
ADDITIONAL INSP. DATE (multi-day)
September 08, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
11:00 AM
DEPARTURE
02:15 PM
ARRIVAL
10:00 AM
DEPARTURE
11:00 AM
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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The routine inspection of the physical facility found:

*The front door had paint worn off down to the wood
*Staff room chair material was worn off of the arms rests and front
*Bent blinds in the kitchen/dining area
*Dining table has chips in the surface exposing the raw wood
*Worn paint on the chair rail in the hallway
*Laminate floor outside the laundry room is worn
*Wood worn down to raw wood in couch base
*Wall damage to the corner of the entrance to the large bedroom and the ramp at the sliding door is broken along the edge and not level
Corrective Action(s): Ensure that all furniture and equipment is maintained in a good state of repair
Date to be Corrected: Sept 21,2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Inspection of the physical facility found:

*Wall panelling missing at the front entrance
*Wall damages to paint and drywall through out the facility
*Baseboards not secured to the walls and damage to paint and drywall

Corrective Action(s): ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: Sept 21, 2021

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: The floor in the large shower room tile floor is stained and grout is dark
Corrective Action(s): ensure all rooms and common areas are maintained in a clean condition
Date to be Corrected: Sept 21, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31350 - RCR s.23(c) - A licensee must ensure that (c) if necessary for the safety of the person in care, a person in care who is smoking or using tobacco, using an e-cigarette or holding an activated e-cigarette is supervised.
Observation: Inspection of the physical facility found a large number of cigarette butts located beside the garage, behind the dumpster and inside the garage door. There is a high risk practice which could lead to fire causing harm to PIC's
Corrective Action(s): Ensure that all residence who smoke are monitored while smoking on facility property to avoid fire risk
Date to be Corrected: Sept 10, 2021

CARE AND/OR SUPERVISION: 34600 - RCR s.81(3)(a)(i) - A care plan must include all of the following: (a) a plan to address (i) medication, including self-administered medication if approved under section 70 (4) [administration of medication].
Observation: Review of 4 care plans noted that 2 PIC's did not have medication self administration plans
Corrective Action(s): Ensure all PIC's who self administer medication have a plan included in their care plan
Date to be Corrected: Sept 21, 2021

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: Review of 4 care plans found that 2 PIC's care plans had not been updated to reflect substantial changes in care needs
Corrective Action(s): ensure all care plans are reviewed and revised when necessary
Date to be Corrected: Sept 21, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Review of 4 care plans found that 1 PIC was missing their immunization record and 1 PIC was missing both TB and immunization records
Corrective Action(s): Ensure all PIC's comply with the provinces immunization and TB programs
Date to be Corrected: Sept 21 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: Inspection of the freezer in the garage noted that there was no thermometer or temperature log for the freezer
Corrective Action(s): Ensure that all food is safely stored
Date to be Corrected: Sept 10, 2021


Comments

Thank you to the staff and management for their support during the routine inspection - during the inspection a JIBC practicum student was present for learning purposes

It was noted during the inspection that one fire extinguisher was not tagged as it was new bought from home depot and will be checked and tagged at next inspection in November

The policy manual is under review currently as the agency is preparing for CARF accreditation

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
Sep 21, 2021

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