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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CLXRZ6
FACILITY NAME
Matthew's House		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
TBIU-8UZNB2
FACILITY ADDRESS
Removed at operator's request		FACILITY PHONE
Removed at operator's request
CITY
Abbotsford		POSTAL CODE
Removed at operator's request		MANAGER
Removed at operator's request
INSPECTION DATE
December 09, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
09:00 AM		DEPARTURE
01:00 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Water temperature was taken in two areas accessible to persons in care, both areas had water temperatures that exceeded 49 degrees.
Corrective Action(s): Ensure that water assessable to persons in care, from any sources, is not heated to more than 49 degrees.
Date to be Corrected: December 23, 2022.

NUTRITION AND FOOD SERVICES: 37010 - RCR s.62(1)(a) - A licensee must ensure that a menu, made in accordance with this section, is developed (a) in the case of a community care facility in which persons in care are accommodated for 6 weeks or fewer, for at least each weekly period.
Observation: Though there are 4 weeks of menus for fall/winter, the same snack and meal items are served each weekday, on each of the 4 weeks (ie.) Monday's menus all the same, Tuesday's, etc.
Corrective Action(s): Please ensure there is a variety of snacks and meals served, and a 4 week menu is developed for the site.
Date to be Corrected: Please submit a plan by December 23, 2022


Comments

It is requested that a written response be submitted on or before December 23, 2022 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.

(Please note: due to infection control practices related to COVID-19 prevention, this inspection report was reviewed with the Manager, written off-site and forwarded to the Licensee. Therefore no signature was obtained.)
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 23, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.