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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B27RQD

FACILITY NAME
Mentmore
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081047
FACILITY ADDRESS
523 Mentmore St
FACILITY PHONE
(604) 931-6551
CITY
Coquitlam
POSTAL CODE
V3J 4P5
MANAGER
Ashley Mann

INSPECTION DATE
June 29, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
11:45 AM
DEPARTURE
02:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and 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)
If you have any questions regarding this report feel free to contact me at 604 949 7710

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-ANKNWB 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: The front step, approximately 3 down from the top has broken away at the lip margin. The fragment would be approximately 10 inches long, 1.5-2 inches deep(front to back). It would pose a significant hazard to anyone entering or exiting the building, particularly if they were in a hurry, as in an emergency, to falling down the stairs. The area has been sectioned off with yellow hazard tape and garden chairs. There is adequate space to go around the stair defect, but the safety measures are unsightly.
The kitchen cupboards all have areas of missing melamine around the perimeters of each cabinet. As well as being worn looking it makes sanitation difficult.
There is a bathroom downstairs that is regularly used by one of the residents. There is significant damage to the ceiling due to a previous toilet leak 1.5 years ago. The paint has bubbled in one area about 4 inches in diameter and the paint has come off, there is also paint missing from around a wallboard seam several inches away from the bubble. It measures approximately 4-6 inches in an x configuration showing the gyproc nail and the seams going in 2 directions. There are also several areas of wrinkled paint in the same section. This is unsightly and not sanitizeable.
Corrective Action(s): Please provide a plan that will ensure that maintenance of this facility takes place in a timely manner to ensure the health, safety and dignity of the residents is maintained.
Date to be Corrected: July 16, 2018


Comments

Sign language translators were present to assist for this inspection.
The facility has a garden in the back yard where residents assist with gardening chores as they wish.
I would like to thanks the staff for their assistance with this inspection.

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
Jul 16, 2018

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