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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-BDJSQM

FACILITY NAME
Manoah Manor
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0982330
FACILITY ADDRESS
100 - 20265 54A Ave
FACILITY PHONE
(604) 530-9895
CITY
Langley City
POSTAL CODE
V3A 3W6
MANAGER
Mike Krabbendam

INSPECTION DATE
June 26, 2019
ADDITIONAL INSP. DATE (multi-day)
June 27, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
09:35 AM
DEPARTURE
03:15 PM
ARRIVAL
02:35 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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, please feel free to contact the geographic area Licensing Officer.

Contraventions
Previous Inspection - Contraventions observed on FIR #NTJN-B2RPJN have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of the MAR determined that medication was administered staff but not documented as required by the MSAC policies and procedures.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: July 15, 2019

CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of the monthly weights determined that one persons in care had gained a significant amount of weight compared to the previous monthly weight record. Further review and discussion with the nursing staff, determined that the person in care needed to be weighed again to ensure that the weight was correct.
Corrective Action(s): Ensure that is there is a significant change in weight that immediate advice is sought from a health care provider.
Date to be Corrected: July 15, 2019


Comments

This LO would like to thank the Manager and Staff for their time and assistance in completing this inspection.

This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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 15, 2019

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