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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SCLY-BH3TEA
FACILITY NAME
Rosedale		SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
LBJE-6HXRCG
FACILITY ADDRESS
Removed at operator's request		FACILITY PHONE
Removed at operator's request
CITY
Chilliwack		POSTAL CODE
Removed at operator's request		MANAGER
Removed at operator's request
INSPECTION DATE
October 17, 2019		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
11:30 AM		DEPARTURE
03:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine 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 (DLSP). 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 https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XXbB7myos2w 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: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: 1 out of 3 medication administration records reviewed found that 1 of them had 10 signatures not present nor any indication for not signing for having administered the medication.
Corrective Action(s): Please ensure that employees follow the medication administration policy and procedure.
Date to be Corrected: Oct 18, 2019

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: 3 out of 3 PICs records did not contain written consent to contact emergency services in the event of an accident or illness.
Corrective Action(s): Please ensure that consents are obtained from each PIC to be able to call a medical or nurse practitioner or ambulance.
Date to be Corrected: Nov 5, 2019

RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: 2 out of 3 person in care (PIC) weight records did not have a weight recorded for September.
Corrective Action(s): Please ensure that PICs are weighed each month.
Date to be Corrected: Oct 18, 2019
Comments

The fish tank downstairs has a lot of algae in it. The manager indicated that staff are going to clean it.

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
Nov 05, 2019
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.