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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AZ9TCD

FACILITY NAME
Augustine House
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
MLAO-5UJNWS
FACILITY ADDRESS
3820 Arthur Dr
FACILITY PHONE
(604) 940-6005
CITY
Delta
POSTAL CODE
V4K 5E6
MANAGER
Tanya Snow

INSPECTION DATE
May 30, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
12:15 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 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 (CORRECTED DURING INSPECTION): In two person in care's bathroom sink, the water temperature read 51.1 degrees Celsius.
Corrective Action(s): Maintenance personal adjusted temperature during inspection. Review of temperatures are completed daily. Please ensure water accessible to persons in care do not exceed 49 degrees Celsius.
Date to be Corrected: June 29, 2018

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 (CORRECTED DURING INSPECTION): The cooking range in the dining area used during recreation programs or to heat food for persons in care was observed to be not turned off at main kill switch in nursing unit, making it potentially accessible to persons in care without supervision. Review with manager and LPN on shift, the cooking range should be turned off at main switch after use.
Corrective Action(s): Ensure all areas are maintained in a safe condition.
Date to be Corrected: June 29, 2018

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: Of four persons in care's records reviewed, one person in care's record did not have the compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Ensure all persons admitted comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: June 29, 2018

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): Review of the main fridge in the dining area, four "Boost" dietary drinks were approximately three weeks past expiry. One sauce was observed without a name label of item or date. It was stated by staff that it is staff food.
Corrective Action(s): Items were removed during inspection. Ensure all food is safely stored.
Date to be Corrected: June 29, 2018

RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: In four person in care's files, it was observed the height was not recorded on admission.
Corrective Action(s): Ensure the height is recorded on admission, along with the weight.
Date to be Corrected: June 29, 2018


Comments


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
Jun 29, 2018

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