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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CMTS2J

FACILITY NAME
Maple Ridge Seniors Village
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9VR4
FACILITY ADDRESS
22141 119th Ave
FACILITY PHONE
(604) 466-3053
CITY
Maple Ridge
POSTAL CODE
V2X 2Y7
MANAGER
Bianca Goldberg

INSPECTION DATE
January 06, 2023
ADDITIONAL INSP. DATE (multi-day)
January 09, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
12
ARRIVAL
10:30 AM
DEPARTURE
03:30 PM
ARRIVAL
09:00 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
108

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 https://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
LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: An external inspection of the front of the facility found two large panels of the fence that were removed, construction workers were observed to be digging a hole into the ground using a jackhammer. No Health and Safety plan was submitted to Licensing prior to commencing this work.
Corrective Action(s): The Licensee is responsible to develop and submit a Health and Safety plan to Licensing prior to commencing work for acceptance as to ensure the health and safety of the persons in care and to ensure the plan is implemented, maintained, and monitored for effectiveness.
Date to be Corrected: February 6, 2023

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: The following were noted upon inspection of the physical facility:
- The heater located in the vestibule at the front entrance of the facility was observed to have a panel detached from the unit.
- The baseboard located on the third floor (east) measuring approximately a foot in length was missing from the wall.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 6, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation (CORRECTED DURING INSPECTION): Review of 2 of 10 admission records found incomplete records of immunization for persons in care.
Corrective Action(s): A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: February 6, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation (CORRECTED DURING INSPECTION): Inspection of the third floor shower room (east hallway) found two shampoos and body wash without any labels or identifiers.
Corrective Action(s): Ensure items are labelled or placed in individual containers for PIC.
Date to be Corrected: February 6, 2023


Comments

I would like to thank the team at Maple Ridge Seniors Village for their time and assistance in the completing this inspection. Please submit a written response by February 6, 2023 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report. This inspection report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Feb 06, 2023

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