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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AVLVER

FACILITY NAME
Menno Place - Menno Home
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0775014
FACILITY ADDRESS
32910 Brundige Ave
FACILITY PHONE
(604) 853-2411
CITY
Abbotsford
POSTAL CODE
V2S 1N2
MANAGER
Karen L. Baillie

INSPECTION DATE
January 29, 2018
ADDITIONAL INSP. DATE (multi-day)
February 02, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10
ARRIVAL
01:00 PM
DEPARTURE
04:00 PM
ARRIVAL
10:00 AM
DEPARTURE
05:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32083 - RCR s.37(3)(c) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of volunteer files, one file did not have a copy of the evidence that the person has complied with the Provnce's immunization and tuberculosis control programs.
Corrective Action(s): Ensure the following documentation is obtained first: compliance with the Provnce's immunization and tuberculosis control programs.
Date to be Corrected: March 2, 2018

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: During meal time in one resident dining room, one staff member was using their bare hands to place cornbread onto plates just prior to serving.
Corrective Action(s): It was stated by the food service manager that the expectation is staff wear gloves to pick up food items when serving.
Ensure all food is safely served and handled.
Date to be Corrected: March 2, 2018

NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Review of menus and discussion with the dietician, a specific menu for one person in care did not have a menu audit completed to ensure that the person in care needs are met as per the Canada's Food Guide.
Corrective Action(s): Ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Date to be Corrected: March 2, 2018


Comments

Review of facility renovations: appear appropriate and as per renovation plans prior to commencement of work.

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 02, 2018

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