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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-BE4PH7
FACILITY NAME
Manuel House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
DCON-6UQPM9
FACILITY ADDRESS
1709 232nd St		FACILITY PHONE
(604) 514-0146
CITY
Langley		POSTAL CODE
V2Z 1K7		MANAGER
Hamish Taylor
INSPECTION DATE
July 08, 2019		ADDITIONAL INSP. DATE (multi-day)
July 12, 2019		ADDITIONAL INSP. DATE (multi-day)
July 15, 2019		TIME SPENT (HRS.)
5
ARRIVAL
12:45 PM		DEPARTURE
01:05 PM		ARRIVAL
10:00 AM		DEPARTURE
11:20 AM		ARRIVAL
10:35 AM		DEPARTURE
02:00 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 www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report, please feel free to the area Licensing Officer.
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: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Review of the main living areas found that the carpet was ripped and exposing two large three foot tears which show the sub-flooring.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 15, 2019

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: Review of the front walkway found that the walkway had sunken approximately 3 inches in depth and showing an exposed that was approximately 4 feet long.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: August 15, 2019

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of the MAR determined that staff did not follow the MSAC policy for second signature checks as there were two dates where the second signatures were missing. It was also confirmed that one person in care (PIC) was away and staff did not mark the MAR for the correct code and left the MAR blank.
Corrective Action(s): Ensure that all employee comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: August 15, 2019
Comments

This LO would like to thank the Manger and Staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. 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
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Aug 15, 2019
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.