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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BKZRML
FACILITY NAME
Mentmore		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081047
FACILITY ADDRESS
523 Mentmore St		FACILITY PHONE
(604) 931-6551
CITY
Coquitlam		POSTAL CODE
V3J 4P5		MANAGER
Ashley Mann
INSPECTION DATE
January 06, 2020		ADDITIONAL INSP. DATE (multi-day)
January 20, 2020		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM		DEPARTURE
03:00 PM		ARRIVAL
02:00 PM		DEPARTURE
03:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (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.
The following areas were reviewed:
· Licensing · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this 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 and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Upon inspection of all PIC (Patient in care) rooms, it was noted that one PIC bedroom had a beside dresser drawer removed and placed on the floor posing a trip and fall hazard.
Corrective Action(s): Ensure that bedroom floor is maintained in a safe condition to prevent any trips and falls.
Date to be Corrected: January 17, 2020

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Upon inspection of the physical facility, it was noted that one PIC had a fridge where he stored his food supplies with staff assistance but no temperature monitoring was recorded. for this fridge
Corrective Action(s): Please ensure that fridge temperature is documented as per facility policy.
Date to be Corrected: January 17, 2020
Comments

The Licensing Officer (LO) would like to thank the Manager, team leader and sign language translator for their time and assistance in completing this routine inspection. On January 6th, 2020, as per manager a computer error was showing PICs negative financial records balance. She was working with her team at Head office to address this for review on January 17, 2020. The error has been corrected as of January 20, 2020.

This report was reviewed and discussed with team lead. A copy of this report was left at the facility.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.