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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-BMFQSL
FACILITY NAME
Maple Ridge Treatment Centre		SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
1081238
FACILITY ADDRESS
22269 Callaghan Ave		FACILITY PHONE
(604) 467-3471
CITY
Maple Ridge		POSTAL CODE
V2X 2E2		MANAGER
Shannon Emery
INSPECTION DATE
March 05, 2020		ADDITIONAL INSP. DATE (multi-day)
March 06, 2020		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9
ARRIVAL
10:00 AM		DEPARTURE
05:00 PM		ARRIVAL
10:15 AM		DEPARTURE
12:00 PM		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/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: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Audit of 6 policies reflected review dates of 2016 to 2017, and one with review date of 2011.
Corrective Action(s): Review and, if necessary, revision of required policies is to be conducted on an annual basis. Ensure a system in place to confirm annual review/ revision to ensure most current policies are in place.
Date to be Corrected: April 6, 2020

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: 1 of 5 care records did not have confirmation of TB test. The person in care was admitted in a timeframe in which TB results would be provided.
Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Province’s tuberculosis control programs.
Date to be Corrected: April 6, 2020
Comments

Licensing has provided the following resources:
- Tuberculosis Guidellines
- Online Incident reporting instructions and definitions
- Bulletin: Required Policies and Procedures
- Director of Licensing Standard of Practice: Preventing Opioid Overdose Deaths
Consent to Care Facility Admission
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
Apr 06, 2020
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Click here for a description of each "Category" of violation displayed.