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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KPRK-CCMNSP
FACILITY NAME
Campbell House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
TDAH-7Z8QHB
FACILITY ADDRESS
21351 Campbell Ave		FACILITY PHONE
(604) 463-7101
CITY
Maple Ridge		POSTAL CODE
V2X 7G6		MANAGER
Kim Rilka
INSPECTION DATE
March 09, 2022		ADDITIONAL INSP. DATE (multi-day)
March 15, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
09:30 AM		DEPARTURE
03:00 PM		ARRIVAL
10:00 AM		DEPARTURE
12:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was conducted 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 (DLSP).   
 The following areas were reviewed: 
 
- Licensing 
- Physical Facility 
- Staffing 
- Policies and Procedures 
- Care and Supervision 
- Hygiene and Communicable Disease Control 
- Medication 
- Nutrition and Food Services 
- Program 

Licensing was unable to fully review records and reporting area during this inspection and a full review will be conducted at the next inspection. 

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: Licensing noted the following damage in one bathroom: 
- A sidewall along the bathtub had exposed dry wall and rust to a height of approximately 18” from the floor. 
- A section of tile (approximately 6” x 2”) was missing at the base of the tub exposing the under flooring.  Exposed edges of tile had rough texture. The home had covered this section with a towel to reduce risk of injury to the persons in care. 
- A shower tile had a 4” x 2” section missing.   
- Mildew was present throughout the length of tub where it met the wall tiles. 
Corrective Action(s): Ensure common areas are maintained in safe and clean conditions. 
Date to be Corrected: May 20, 2022

CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: Nutritional assessments were not completed for three Persons in Care.
Corrective Action(s): Ensure nutrition plans assess nutritional status.
Date to be Corrected: April 29, 2022

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: A Care Plan provided staff guidance on what actions they needed to take regarding a medical condition. Staff failed to follow the actions listed in the care plan on at least three occasions.
Corrective Action(s): Ensure the terms and conditions of care plans are implemented.
Date to be Corrected: April 15, 2022
Comments

Licensing discussed planned renovations and environmental restraints during this inspection.

As part of this routine inspection a facility risk assessment tool is completed.  The risk assessment includes contraventions identified during the routine inspection and a 3-year historical review of the facility's compliance and operation. This Licensing Officer would like to thank the staff for their assistance in completing this routine inspection.  Please provide a response to Licensing by April 29, 2022 as to how the identified items in this report will be addressed. 

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report. 
(Please note: this inspection report was written off-site and later reviewed and forwarded to the Licensee.  Therefore, no signature was obtained.) 
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 29, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.