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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-D2NQVG

FACILITY NAME
Menno Place - Menno Hospital
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTYY
FACILITY ADDRESS
32945 Marshall Rd
FACILITY PHONE
(604) 859-7631
CITY
Abbotsford
POSTAL CODE
V2S 1K1
MANAGER
Smitha Varghese

INSPECTION DATE
February 21, 2024
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
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.

Observed Violations
No violations were found during the inspection.

Comments

It was observed that all care systems are implemented and that the facility operates in compliance with legislation. Self-monitoring is comprehensive and regular with review for improvement.

Discussed during inspection:
-Recreation plans
-menus & snack menu & audits

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
No action requiredNo action required

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