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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CXZP2D

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
Ann Marie Leijen

INSPECTION DATE
November 28, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
10:00 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled 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 during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & 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 -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Review of 6 staff files found that 2 staff did not have evidence of current First Aid certification.
Corrective Action(s): Ensure all staff have the necessary skills and training, and the facility retains copies of the certificates.
Date to be Corrected: December 8, 2023


Comments

Discussed during inspection:
-Current building renovations
-MSAC policies, procedures and audits
-Dietician referrals
-Staffing contractor change to Provita in December of 2022 - reference checks and performance reviews

It is requested that a written response be submitted on or before December 8, 2023 describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

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
Dec 08, 2023

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