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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CPBNLR

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, 2023
ADDITIONAL INSP. DATE (multi-day)
February 24, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
09:30 AM
DEPARTURE
03:30 PM
ARRIVAL
09:00 AM
DEPARTURE
10:00 AM
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: Water temperatures were sampled throughout the building, 4 of 5 samples exceeded 49 degrees. The temperatures were as high as 61 degrees. It was noted that the facility has been actively working to find a remedy to the fluctuating water temperatures.
Corrective Action(s): Ensure that water accessible to persons in care, from any source is not heated more than 49 degrees.
Date to be Corrected: March 3, 2023

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: 3 of 5 person in care records reviewed did not have documentation to confirm if the person in care was encouraged to see a dental health care professional, at least once per year. The other 2 persons in care had not been in care for a full year.
Corrective Action(s): Ensure persons in care are encouraged to be examined by a dental health care professional at least once per year.
Date to be Corrected: March 3, 2023


Comments

It is requested that a written response be submitted on or before March 3, 2023 describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

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
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Mar 03, 2023

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