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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-B9EPDL

FACILITY NAME
Maplewood House
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0703867
FACILITY ADDRESS
1919 Jackson St
FACILITY PHONE
(604) 853-5585
CITY
Abbotsford
POSTAL CODE
V2S 2Z8
MANAGER
Heidi Mannis

INSPECTION DATE
February 14, 2019
ADDITIONAL INSP. DATE (multi-day)
February 15, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10.5
ARRIVAL
09:30 AM
DEPARTURE
04:00 PM
ARRIVAL
10:00 AM
DEPARTURE
11:00 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

A scheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (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.

Care systems reviewed include the following:

Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & Reporting
Resident Bill of Rights
Additional CCALA Sections

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 -
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: It was observed that 2 of the 4 water temperatures tested from sources accessible to persons in care, was above 49 degrees.
Corrective Action(s): Ensure that all water sources accessible to a person in care, is not heated to more than 49 degrees.
Date to be Corrected: 22 Feb 2019

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: It was observed in one bathing facility that the wall had significant damage with exposed drywall. Of concern is the lack of ability to adequately clean this area due to the damage.
Corrective Action(s): Please ensure all common areas are maintained in a good state of repair.
Date to be Corrected: 28 Feb 2019

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: It was observed in the walk-in cooler in the kitchen that there were food items that were plated but not labelled with a date.
Corrective Action(s): Ensure that all food items are labelled and dated to prevent any risk of ingesting expired food items.
Date to be Corrected: 22 Feb 2019


Comments

The Community Care and Assisted Living Act and pursuant Residential Care Regulations set the minimum standards that must be met by all licensees of licensed care facilities to ensure the health and safety of vulnerable individuals in care. The responsibility rests with Maplewood House to provide for the health and safety needs of all individuals in your care at all times.

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
Feb 22, 2019

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