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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AGNQ7H
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
December 13, 2016		ADDITIONAL INSP. DATE (multi-day)
December 14, 2016		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10
ARRIVAL
01:00 PM		DEPARTURE
04:15 PM		ARRIVAL
10:30 AM		DEPARTURE
04:30 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 - 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
RECORDS AND REPORTING: 39440 - RCR s.86(d) - A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Observation: In an audit of 7 staff records, one staff did not have the initial performance review in the appropriate timed manner. The initial performance review is conducted when a staff person has completed 450 work hours.
Corrective Action(s): Ensure performance reviews are completed at the appropriate times when work hours are completed as per Menno Policy.
Date to be Corrected: January 13, 2017
Comments

The following was discussed with the Director of Care:
In review of one double occupancy room, the curtains for the bathroom were hung on the opposite rods making closure difficult. It is recommended a similar system for magnets be used to assist in closing the blinds fully for privacy are used in these bathrooms with double curtains as have been added to other rooms with two curtains where lifts have been placed.
The facility is participating in "Save Our Skin" (SOS) Wound Care initiative. This process will include the Dietician being involved at Stage 1 of wound care instead of Stage 2, where they are presently involved.
Point of Care - essentially documentation of Resident daily routines and observations has been initiated at this facility. As this program is being facilitated, the Director of Care will be involved in delegating the monitoring and auditting of the program once fully established.
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
Jan 13, 2017
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Click here for a description of each "Category" of violation displayed.