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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

JKAS-CP9PHS

FACILITY NAME Murrayville Manor		SERVICE TYPES 120 Mental Health	FACILITY LICENSE # 0982850
FACILITY ADDRESS 21616 46th Ave			FACILITY PHONE (604) 530-9033
CITY Langley	POSTAL CODE V3A 3J4		MANAGER Lori Crowley

INSPECTION DATE February 21, 2023	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 5
ARRIVAL 10:30 AM	DEPARTURE 03:30 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 35

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

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.

Visit the CCFL website at https://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: 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: Noted during physical inspection of a shower room- 3 unlabelled personal care items were found in the shared space.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in safe and clean condition.
Date to be Corrected: March 7, 2023

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: Review of 5 Persons in Care (PICs) charts determines that 2 of 5 PICs do not have evidence TB and historical vaccination.
Corrective Action(s): Please ensure that all PICs chart have evidence showing compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: March 7, 2023

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 5 PICs charts determined that 1 of 5 PICs is missing evidence of 3 weights over the last 12 months.
Corrective Action(s): Please ensure that each PIC is weighed at least once each month
Date to be Corrected: March 7, 2023

Comments

This Licensing Officer would like to thank the Staff for their assistance in completing this routine inspection.

Please provide a written response by March 7, 2023 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was reviewed with the staff on site and signed. It was then provided with the corresponding risk assessment to the Licensee via email.)

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Mar 07, 2023

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