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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
DBED-AWE2G7

FACILITY NAME
Menno Place - Menno Hospital
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTYY
FACILITY ADDRESS
32945 Marshall Rd
FACILITY PHONE
(604) 859-7631
CITY
Abbotsford
POSTAL CODE
V2S 1K1
MANAGER
Cyndy Gabriel

INSPECTION DATE
February 22, 2018
ADDITIONAL INSP. DATE (multi-day)
February 23, 2018
ADDITIONAL INSP. DATE (multi-day)
February 27, 2018
TIME SPENT (HRS.)
14
ARRIVAL
11:00 AM
DEPARTURE
04:00 PM
ARRIVAL
08:30 AM
DEPARTURE
03:30 PM
ARRIVAL
09:00 AM
DEPARTURE
11:00 AM
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

Routine Inspection Introduction
An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA) 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.

Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for:
· Additional resources, and
· Links to the Legislation (CCALA and CCLR)

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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Large cabinets throughout the facility common areas and various bedrooms are not secured.
Corrective Action(s): Ensure all rooms and common areas are maintained in a safe condition.
Date to be Corrected: March 13th, 2018

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: A bottle of bleach was stored in the food service area in the open on the top shelf above the sink.
Corrective Action(s): Corrected During Inspection
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: First floor dining room/ food service area orange juice and peanut butter in fridge not dated or labelled. .
Second unit dining room/food service area 3 cake mixes were found outdated (2017) along with a container of Hershey Cocoa (08/2016)
Third unit dining room/food service area two trays were sitting on top of counter with food and fluids only partially covered for over 45 minutes.
Corrective Action(s): Ensure food is safely stored, covered and labelled.
Date to be Corrected: Corrected During Inspection


Comments

The following policies and procedures were reviewed: Falls Prevention; Restraints and Complaint Concern Process

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Mar 13, 2018

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