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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-B5WLPA
FACILITY NAME
Mill Lake Residence		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0720035
FACILITY ADDRESS
33056 Mill Lake Rd		FACILITY PHONE
(604) 854-2911
CITY
Abbotsford		POSTAL CODE
V2S 2A3		MANAGER
Trisha Ambridge
INSPECTION DATE
October 24, 2018		ADDITIONAL INSP. DATE (multi-day)
October 26, 2018		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
12:30 PM		DEPARTURE
04:00 PM		ARRIVAL
11:30 AM		DEPARTURE
12:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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 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 - Contraventions observed on FIR #KDHL-AS2Q4S have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: Review of three persons in care's records found that one person in care was missing entries in the monthly weight record with no reason indicating why the person in care was not weighed.
Corrective Action(s): Ensure all persons in care are weighed monthly and if a person in care refuses or is unable to be weighed, record the reason why.
Date to be Corrected: 26 Oct 2018
Comments

It was noted at the time of the inspection that health care plans for all persons in care had not been reviewed, however discussion with the team lead indicated that a health care plan review had occurred the day prior, 23 Oct 2018, and the updated documentation was expected to be in place by 26 Oct 2018. It was confirmed that they are in place as of 25 Oct 2018.
Second day of inspection was at head office of MSA Society for Community Living to review staff files and to deliver report. Inspection report was reviewed and delivered to Manager.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Oct 26, 2018
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Click here for a description of each "Category" of violation displayed.