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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
HRM-007

FACILITY NAME
Holyrood Manor
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTLK
FACILITY ADDRESS
22710 Holyrood Av
FACILITY PHONE
(604) 467-8831
CITY
Maple Ridge
POSTAL CODE
V2X 3E6
MANAGER
Michael Neumann

INSPECTION DATE
June 29, 2017
ADDITIONAL INSP. DATE (multi-day)
June 30, 2017
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
0.01
ARRIVAL
08:00 AM
DEPARTURE
04:00 PM
ARRIVAL
08:00 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction


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: 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:
Corrective Action(s):
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31810 - RCR s.36(1)(b) - A licensee must provide outside activity areas that have (b) a surfaced patio area.
Observation:
Corrective Action(s):
Date to be Corrected:

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31820 - RCR s.36(1)(c) - A licensee must provide outside activity areas that have (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather.
Observation:
Corrective Action(s):
Date to be Corrected:

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:
Corrective Action(s):
Date to be Corrected:

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:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34440 - RCR s.73(2)(a) - In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (a) all alternatives to the use of the restraint must have been considered and either implemented or rejected.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34470 - RCR s.73(2)(c) - In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34620 - RCR s.81(3)(a)(iii) - A care plan must include all of the following: (a) a plan to address (iii) if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment.
Observation:
Corrective Action(s):
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39340 - RCR s.84(a) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (a) the type or nature of the restraint used.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39350 - RCR s.84(b) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (b) the reason for the use of the restraint.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39360 - RCR s.84(c) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (c) the alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39380 - RCR s.84(e) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (e) the result of any reassessment of the use of the restraint.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39590 - RCR s.91(1)(b) - A licensee must ensure that all records referred to in this regulation (b) if the licensee operates more than one community care facility, are kept separately for each community care facility.
Observation:
Corrective Action(s):
Date to be Corrected:


Comments


Action Required by Licensee/ManagerAction Required by Licensing Staff
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Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.