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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CC4NLT
FACILITY NAME
Mayfair (The)		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
TBIU-9L9MMF
FACILITY ADDRESS
33433 Marshall Rd		FACILITY PHONE
(604) 855-7217
CITY
Abbotsford		POSTAL CODE
V2S 1K8		MANAGER
Azita Babai
INSPECTION DATE
February 23, 2022		ADDITIONAL INSP. DATE (multi-day)
March 24, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
12:30 PM		DEPARTURE
01:30 PM		ARRIVAL
08:30 AM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & 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: The water temperature was sampled throughout the facility, and in all areas the temperature exceeded 49 degrees. Temps were noted to be between 51-66 degrees.
Corrective Action(s): Ensure water accessible to persons in care, is not heated to more than 49 degrees Celsius.
Date to be Corrected: March 4, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): It was observed in 3 or more kitchenette areas, accessible to persons in care, that there were chemicals stored under the sink, and the lock was either not working or not engaged.
Corrective Action(s): Immediate action was taken, and locks were replaced and engaged by the end of the inspection, securing the items under the sinks.
Date to be Corrected: corrected
Comments

During the inspection is was noted that one emergency exit had been missed, and was not updated as per the mitigation of risk strategy. This issue was addressed on the day of inspection and will be confirmed in a follow up inspection.
Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.
Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required
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