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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

KDHL-BXUUHX

FACILITY NAME Matthew's House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # TBIU-8UZNB2
FACILITY ADDRESS Removed at operator's request			FACILITY PHONE Removed at operator's request
CITY Abbotsford	POSTAL CODE Removed at operator's request		MANAGER Removed at operator's request

INSPECTION DATE February 02, 2021	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.75
ARRIVAL 11:15 AM	DEPARTURE 03:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
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 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

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Review of the First Aid Kit checklist, determined checklists for 4 months out of 2 years reviewed were not signed and dated as part of completion of the checklist. Corrective Action(s): Ensure staff implement policy Date to be Corrected: March 2, 2021

Comments

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 02, 2021

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