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

FACILITY NAME
Mayfair (The)
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
TBIU-9L9MMF
FACILITY ADDRESS
33433 Marshall Rd
FACILITY PHONE
(604) 855-7217
CITY
Abbotsford
POSTAL CODE
V2S 1K8
MANAGER
Marilyn Smart

INSPECTION DATE
March 27, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
09:30 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
80

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records and Reporting

As part of this 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.

Contraventions
Previous Inspection - Not Applicable
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: Inspection of the janitor's room found the drywall had 2 areas with significant damage.
Corrective Action(s): Ensure all rooms are maintained in a good state of repair.
Date to be Corrected: 12 April 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: Upon inspection of the walk-in freezer, there was food repackaged into freezer bags that were not labelled with a date.
Corrective Action(s): Ensure all food is safely stored.
Date to be Corrected: 29 Mar 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 The Mayfair 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
Apr 12, 2019

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