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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSTT-D2FVZR

FACILITY NAME
Beckman House
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
AKLN-6BVM5L
FACILITY ADDRESS
12032 216th St
FACILITY PHONE
(604) 466-3370
CITY
Maple Ridge
POSTAL CODE
V2X 5J3
MANAGER
Michelle Demmitt

INSPECTION DATE
February 23, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.4
ARRIVAL
11:50 AM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include:
· Licensing
· Physical Facility
· Staffing
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records & 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The hot water was tested in the women and men's bathroom. Temperatures were recorded at 54.1 Celsius.Water was turned down after the last routine inspection, however there is currently no system in place to monitor the water temperature.
Corrective Action(s): A licensee must ensure that water accessible to person's in care is not more then 49' Celsius
Date to be Corrected: March 8 2024

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): Upon review of the facility, a bottle of beach was observed in the laundry room cupboard, and additional cleaning chemicals were observed in one of the shared bathrooms, both of which are accessible to the person's in care,
Corrective Action(s): A licensee must provide secure, safe and adequate storage for cleaning agents, chemical products and other hazardous materials
Date to be Corrected:

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: Upon review of the Person's in care files, 2 out of 5 did not have evidence of compliance with the provinces immunization and tuberculosis
Corrective Action(s): A licensee must ensure all persons admitted to a community care facility comply with the Provinces immunization and tuberculosis program
Date to be Corrected: March 8 2024

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: It was observed that the dishwasher is not working which has been reported and the facility is waiting on parts to repair this. Staff are using paper/plastic plates and cutlery for serving food in the mean time, however there is concern with how the cooking tools are being washed and sanitized.
Corrective Action(s): A licensee must ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: March 8 2024


Comments

It was observed that the men's washroom still has a very strong odour present and the damage to the walls in the dining room has not been repaired. These issues were reported to the funder and will not be addressed till new fiscal year. Follow-up on these item is required.

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
Mar 08, 2024

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