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
JSAT-CPWLNX
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
Kim Scott
INSPECTION DATE
March 13, 2023		ADDITIONAL INSP. DATE (multi-day)
March 14, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9
ARRIVAL
12:00 PM		DEPARTURE
04:00 PM		ARRIVAL
09:00 AM		DEPARTURE
02:00 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) and 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
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: 2 of 5 person in care files reviewed did not have documentation of encouragement to see a dental health care professional in the past year.
Corrective Action(s): Ensure that each person in care is examined by a dental health professional at least once each year.
Date to be Corrected: March 31, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: 2 of 5 PIC files reviewed did not have evidence of a completed screening form for immunizations.
Corrective Action(s): Ensure that all persons in care comply with the Province's immunization and TB control programs.
Date to be Corrected: March 31, 2023

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: 2 of 5 persons in care were not weighed for 2 months, of the past 12 months reviewed. There was no explanation documented for the same.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: March 31, 2023

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: The menu substitution list was not available for review at the time of inspection. It was reported by staff that the site does keep a substitution list, but they could not find it on either day of inspection.
Corrective Action(s): Ensure records are kept regarding food substitutions.
Date to be Corrected: March 31, 2023
Comments

It is requested that a written response be submitted on or before March 31, 2023 describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.
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
Mar 31, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.