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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KPRK-CG9Q9L

FACILITY NAME
Montgomery House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081105
FACILITY ADDRESS
227 Montgomery St
FACILITY PHONE
(604) 936-3171
CITY
Coquitlam
POSTAL CODE
V3K 5E7
MANAGER
Kelly Ternes

INSPECTION DATE
July 08, 2022
ADDITIONAL INSP. DATE (multi-day)
July 11, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
10:00 AM
DEPARTURE
11:45 AM
ARRIVAL
09:15 AM
DEPARTURE
12:30 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 Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DLSP).
The following areas were reviewed:

- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

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: 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: Licensing observed the following in the outdoor space:
- Overgrown, thorny blackberry bushes spanning the length of the backyard
- Dirt and moss covering approximately 30% of the railings
- Weeds (up to 24 cm height) in and around three raised planter boxes
- Paint worn from approximately 50% of the porch and stairs
Corrective Action(s): Ensure common areas are maintained in a safe and clean condition.
Date to be Corrected: July 29, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation (CORRECTED DURING INSPECTION): The laundry area is accessible and used by the persons in care. Licensing observed the area to be without a slip resistant floor surface.
Corrective Action(s):
Date to be Corrected:

MEDICATION: 36060 - RCR s.68(2)(c) - A licensee must appoint a supervising pharmacist to (c) consult with employees respecting medication interactions and other problems related to medication.
Observation: Records of consultation with the pharacist were not available (medication safety and advisory meeting, medication reviews). Related legislation: Health Professionals Act, Bylaws - Schedule F Part 3.
Corrective Action(s): Ensure the pharmacist consults with employees respecting problems related to medication.
Date to be Corrected: July 22, 2022

RECORDS AND REPORTING: 39230 - RCR s.79(1)(a) - A licensee must keep a record in respect of each person in care showing the following information: (a) all money, valuables and other things held by the licensee in trust or safekeeping for persons in care.
Observation: Three gift cards belonging to a PIC were undocumented. The balances on the cards were not documented or checked since held by the licensee.
Corrective Action(s): Ensure a record is kept of all valuables held in trust.
Date to be Corrected: July 22, 2022


Comments

As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.
Due to technical issues at home the inspection was completed over two days. This Licensing Officer would like to thank the staff for their assistance in completing this routine inspection.

Please provide a response to Licensing by July 22, 2022 as to how the identified items in this report will be addressed.
Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
(Please note: this inspection report was written off-site and later reviewed and forwarded to the Licensee. Therefore no signature was obtained.)

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 22, 2022

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