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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-BU7THT

FACILITY NAME
Mountain View Home
SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
0703654
FACILITY ADDRESS
5133 Boundary Rd
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Sarabjit Brar

INSPECTION DATE
October 08, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
11:00 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

A follow up inspection to Routine Inspection JSAT-BMKMMP , dated March 10 & 16th, 2020, was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).

The following care systems were reviewed during this inspection:
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and communicable disease control
- Nutrition and food services
- Records and Reporting

For resources for licensees, links to the Legislation (CCALA and RCR), and Residential Care Facility Inspection Reports posted online go to: www.fraserhealth.ca/residentialcare

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: Review of the emergency supplies, and discussion with the manager determined that there were a number of food items in the emergency kit that were expired. As well as only about one case of 48 small (individual) bottles of water.
Corrective Action(s): Please ensure there is an emergency plan in place that sets out how persons in care will continue to be cared for in the event of an emergency.
Date to be Corrected: November 5, 2020

NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of menu substitution list shows a gap in documentation from February 2020-September 2020. The manager stated that there is a substitution list, but was not able to locate the list.
Corrective Action(s): Please ensure that a record of menu substitutions is kept, and substitutions are made from the same food group, and have a similar nutritional value.
Date to be Corrected: November 5, 2020


Comments

LO provided manager with resources and Bullitins as listed:
-Nutrition and food service component of the Residential Care Regulations
-The role of the food services manager and the Dietician in Community Care facilities (over 24 beds) Part 1
-How to evaluate facility menus
-Licensed Residential care policy, procedure and plan requirements

LO discussed with manager:
-Care plans and policies require evidence of annual review (date and signature of review).
-Please review Menu audits to confirm that correct number of servings is reflected on the menu audit.
-manager is currently creating a system to keep track of date that performance reviews are due, as well as first aid recertification, food safe, criminal record checks etc.

Due to Covid-19 protocols, this report was reviewed with the manager and delivered via e-mail.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Nov 05, 2020

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