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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BVYS6L
FACILITY NAME
Maple Ridge Seniors Village		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9VR4
FACILITY ADDRESS
22141 119th Ave		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Bianca Goldberg
INSPECTION DATE
December 04, 2020		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
11:30 AM		DEPARTURE
02:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

An on-site inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). A Routine Inspection was initiated on March 5, 2020, report NTJN-BMMMGD. The Licensee submitted a compliance plan detailing how and when the non-compliance would be addressed. Follow-up inspections were conducted on March 27th, 2020, June 4th, 2020, and September 24, 2020, to ensure compliance. Each follow-up inspection required a further compliance plan. This inspection will follow-up on the most recent compliance plan received by CCFL on December 4th, 2020. Evidence for this report was based on the Licensing Officer’s (LO) observations, review of facility records, and information provided by facility staff at the time of the inspection.
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: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: On inspection of four persons in care (PIC) rooms, observed in one room was a prescribed topical medication. Of concern is this medication is not stored in a safe and secure area. This is a repeat contravention.
Corrective Action(s): Ensure all medications are safely and securely stored.
Date to be Corrected: December 11, 2020

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): Upon inspection of two bathing rooms, it was observed that one room had a personal grooming item that was not labelled to identify who it belonged to. Of concern is that it could potentially be used by someone other than to whom it belongs to. This is a repeat contravention. This item was removed at the time of the inspection, however it was discussed with facility leadership that there needs to be a system in place to monitor this space to ensure ongoing compliance moving forward.
Corrective Action(s): Ensure there is a program in place to assist PICs in maintaining health and hygiene.
Date to be Corrected: December 11, 2020
Comments

In discussion with facility leadership staff it was determined that although it appears that 32 staff performance evaluations have been conducted as reported in the compliance plan, it was not determined at the time of this inspection how many are overdue at this time. A report will be generated and submitted to CCFL by December 8th, 2020,and contingent upon it, a revised compliance plan may be required.
Further discussion concerning the compliance plan, related to RCR s. 68(4), it was decided that although the facility is now in compliance, this item concerning double signatures for medication administration will continue to be monitored monthly and documented .
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 11, 2020
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.