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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-BCVVEC

FACILITY NAME
Menno Place - Menno Home
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0775014
FACILITY ADDRESS
32910 Brundige Ave
FACILITY PHONE
(604) 853-2411
CITY
Abbotsford
POSTAL CODE
V2S 1N2
MANAGER
Karen L. Baillie

INSPECTION DATE
May 31, 2019
ADDITIONAL INSP. DATE (multi-day)
June 04, 2019
ADDITIONAL INSP. DATE (multi-day)
June 06, 2019
TIME SPENT (HRS.)
8
ARRIVAL
12:30 PM
DEPARTURE
02:00 PM
ARRIVAL
09:45 AM
DEPARTURE
12:15 PM
ARRIVAL
09:40 AM
DEPARTURE
12:30 PM
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 https://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
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Review of program called Workshub where all work orders are entered to be completed by staff determined monitoring of completion for laundry and housekeeping items is not occurring.
Corrective Action(s): Ensure a system of monitoring for all departments to ensure tasks are completed by staff.
Date to be Corrected: July 5, 2019

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: In one shower room, a cleaning brush was left on the floor. Review of the expectation, item should have been hung or with a catch bucket underneath after cleaning of the shower room.
Corrective Action(s): Ensure cleaning brushes are appropriately stored.
Date to be Corrected: July 5, 2019


Comments


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 05, 2019

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