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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-BCVW3G
FACILITY NAME
Menno Place - Menno Hospital		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTYY
FACILITY ADDRESS
32945 Marshall Rd		FACILITY PHONE
(604) 859-7631
CITY
Abbotsford		POSTAL CODE
V2S 1K1		MANAGER
Cyndy Gabriel
INSPECTION DATE
May 31, 2019		ADDITIONAL INSP. DATE (multi-day)
June 04, 2019		ADDITIONAL INSP. DATE (multi-day)
June 06, 2019		TIME SPENT (HRS.)
10
ARRIVAL
02:00 PM		DEPARTURE
04:00 PM		ARRIVAL
12:00 PM		DEPARTURE
04:00 PM		ARRIVAL
12:00 PM		DEPARTURE
04:00 PM
INSPECTION TYPE
Routine		# OBSERVED IN CARE
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 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
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Review of program called Workshub where all work orders are entered to be completed by staff determined monitoring of completion for laundry and housekeeping items is not occurring.
Corrective Action(s): Ensure there is a monitoring system in place for all departments to ensure staff are completing tasks
Date to be Corrected: July 5, 2019
Comments
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
Jul 05, 2019
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.