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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

NBIH-BJQRRC

FACILITY NAME Thornton		SERVICE TYPES 140 Community Living	FACILITY LICENSE # TDAH-82LV3P
FACILITY ADDRESS 11960 249A St			FACILITY PHONE (604) 463-5188
CITY Maple Ridge	POSTAL CODE V4R 2E3		MANAGER Robert Hicks

INSPECTION DATE December 10, 2019	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 1.75
ARRIVAL 11:00 AM	DEPARTURE 12:45 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 4

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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo

Contraventions

Previous Inspection - Contraventions observed on FIR #NBIH-ATJPGY have been corrected.

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: During the inspection it was noted that 3 PIC's care plans had not been reviewed within the last year: 1. previous review September 2018 2. Previous review November 2017 3. Previous review June 2016. Corrective Action(s): Please ensure that care plans are reviewed at least once each year. The manager and the LO discussed the steps for updating the nutritional care plans, the meals and more manual forms were reviewed. Date to be Corrected: March 31 2020

Comments

During the inspection it was also noted that there were minor repairs needed around the facility (chipped paintwork on walls and gutters in need of being cleaned), the manager stated that work orders have been placed for these items and are expected to be completed within the next 3 months. The back fence was also noted to be in need of repair. The manager stated that in the spring of 2020, discussions will be had with the neighbour about replacing or repairing.

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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