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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AXRT7Q

FACILITY NAME
48B
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982194
FACILITY ADDRESS
4515 48B St
FACILITY PHONE
(604) 940-1372
CITY
Delta
POSTAL CODE
V4K 2R9
MANAGER
Marni MacGillivray

INSPECTION DATE
April 12, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:00 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 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
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Staff complete a personal charting document for each person in care at each shift. In addition, staff complete documentation on an online program. Although there is some duplication of information in both areas, the assistant manager stated they are in the process of completely switching to the online system. Until such time it is expected that staff complete both forms of documentation.
Corrective Action(s): Ensure staff implement the processes in place.
Date to be Corrected: May 11, 2018

RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: Review of facility systems and records in place, the following areas were identified with information that was not current:
- in the home binder, one page did not state the most recent admission's name as an individual who resided in the home; as well, review of the daily routines, the night shift document included a discharged person in care's name.
- in The Emergency binder, one person in care's (newest admission) consent card was not included; the fire escape plan had a discharged person in care's name stated on it.
- The fire escape plan posted on the wall also stated a discharged person in care's name and not the newest admission's name.
Corrective Action(s): Ensure all records at the facility are current.
Date to be Corrected: May 11, 2018


Comments

Licensing discussed/ acknowledges the following:
- discussion with the assistant manager regarding updated legislation and guidelines available on Fraser Health's Licensing website, link noted in the introduction of this inspection report.
- all staffing compliance is documented on a staffing checklist which is updated by head office and provided to the manager. As well, the performance reviews are reviewed with staff and then forwarded to head office.

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 11, 2018

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