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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NBIH-ARNRS4

FACILITY NAME
122nd Avenue Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081369
FACILITY ADDRESS
22229 122nd Ave
FACILITY PHONE
(604) 467-8828
CITY
Maple Ridge
POSTAL CODE
V2X 3X8
MANAGER
Linda Blyth

INSPECTION DATE
September 29, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
11:00 AM
DEPARTURE
02:00 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)
If you have any questions regarding this report feel free to contact me at 604-949-7714 or by email at nicholas.birch@fraserhealth.ca

Contraventions
Previous Inspection - Contraventions observed on FIR #SCLY-ADXQM4 have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: A review of 3 PIC's care plans found the following:
- 1 PIC's health care plan was last reviewed in March 2016.
- 1 PIC's health care plan was last reviewed in August 2016.
- 1 PIC's nutritional requirements and mealtime guidelines was last reviewed in May 2016.

Corrective Action(s): Please ensure that PIC's care plans are reviewed at least once each year.
Date to be Corrected: October 31 2017.

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: 1) 2 Freezers in use by the facility are not being monitored for correct temperature ranges to ensure safe food storage.
2) 1 box of expired cereal bars (April 2017) was found in the facility emergency kits.
Corrective Action(s): Please ensure there are systems in place to ensure the safe storage of foods.
Date to be Corrected: October 31 2017

RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: A review of 3 PIC's care plans found 1 with no record of immunization status.
Corrective Action(s): Please ensure that a record of immunization status is kept for all PIC's.
Date to be Corrected: October 31 2017

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: A review of 3 PIC's care plans found that 1 PIC had no signed consent form on file.
Corrective Action(s): Please ensure there is consent (in writing) to call a medical practitioner or ambulance in case of accident or illness kept for all PIC's.
Date to be Corrected: October 31 2017


Comments


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