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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

NBIH-AYZSA9

FACILITY NAME Arborwynd		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081392
FACILITY ADDRESS 27136 112th Ave			FACILITY PHONE (604) 462-0968
CITY Maple Ridge	POSTAL CODE V2W 1P8		MANAGER Donald Vaughn MacPherson

INSPECTION DATE May 22, 2018	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2
ARRIVAL 12:00 PM	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)

Contraventions

Previous Inspection - Contraventions observed on FIR #NBIH-AN5UDH have been corrected.

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned. Observation: As per agency policy, all staff will receive a performance review on an annual basis. A review of the staffing checklist showed that 6 out of 8 staff are overdue for a performance evaluation (all being due in August 2017. The manager stated that these are all in the process of being completed. Corrective Action(s): Please ensure that the performance of each employee is reviewed on a regular basis as per agency policy. Date to be Corrected: July 15 2018

Comments

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

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