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
JSTT-CUXNJP
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
August 22, 2023		ADDITIONAL INSP. DATE (multi-day)
August 23, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.45
ARRIVAL
11:00 AM		DEPARTURE
01:15 PM		ARRIVAL
03:15 PM		DEPARTURE
03:45 PM		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), 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
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Upon review of staffing records, 1 staff has not had their performance review completed as per the facility's annually policy.
Corrective Action(s): A licensee must ensure that performance of each employee is reviewed regularly and as per facility policies
Date to be Corrected: Augus 31 2023
Comments

This inspection was completed over two days as licensing office was unable to access staff records at the time of the inspection.
Licensing returned the second day to finish the inspection which included having the inspection signed. .
Thank you to the staff that were very helpful during 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
Aug 31, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.