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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BJ4TJF

FACILITY NAME
Montgomery House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081105
FACILITY ADDRESS
227 Montgomery St
FACILITY PHONE
(604) 936-3171
CITY
Coquitlam
POSTAL CODE
V3K 5E7
MANAGER
Kelly Ternes

INSPECTION DATE
November 19, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
10:30 AM
DEPARTURE
04:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (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.
The following areas were reviewed:
· Licensing · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this 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 and RCR)

Contraventions
Previous Inspection - Not Applicable
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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Upon inspection of the physical facility, it was noted that the kitchen oven’s bottom compartment door was broken.
Corrective Action(s): Ensure that all equipment for use by PIC's is maintained in a good state of repair. Team Lead informed LO that range was going to be replaced by BC Housing along with new kitchen by January 31st, 2020.
Date to be Corrected: January 31st, 2020

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Upon inspection of the physical facility, it was noted:
1. that the dining room nook area has 3 significant chipped drywall.
2. the kitchen cabinet drawers have paint peeling off and kitchen countertop looks worn out.
Manager mentioned during inspection that BC Housing was going to repair/replace these latest by January 2020.
Corrective Action(s): All person's in care (PIC) common areas and kitchen are maintained in a good state of repair. If there is a delay in the repairs/replacement beyond January 2020, the manager is to inform LO of the same.
Date to be Corrected: January 31st, 2020

POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Upon review of all the required policies, it was found that other than Emergency Plan Policy, remaining policies were reviewed in 2017.
Corrective Action(s): Ensure that all policies are reviewed annually with revisions if necessary.
Date to be Corrected: November 22nd, 2019


Comments

The Licensing Officer (LO) would like to thank the House Manager and Team Lead for their time and assistance in completing this routine inspection. LO was made aware that the facility plans to renovate the common bathtub and kitchen latest by January 2020. The manager has been informed to submit detailed plans to CCFL for approval before commencing any renovation works.
This report was reviewed and discussed with manager. 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
Jan 31, 2020

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