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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-AZFNZ3
FACILITY NAME
Murrayville Manor		SERVICE TYPES
120 Mental Health
FACILITY LICENSE #
0982850
FACILITY ADDRESS
21616 46th Ave		FACILITY PHONE
(604) 530-9033
CITY
Langley		POSTAL CODE
V3A 3J4		MANAGER
Lori Crowley
INSPECTION DATE
June 05, 2018		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
08:45 AM		DEPARTURE
12:45 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and 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)
If you have any questions regarding this report, please feel free to the area Licensing Officer.
Contraventions
Previous Inspection - Contraventions observed on FIR #MMAE-AN5T8R have been corrected except for those noted on supplementary pages.
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: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: A review of 2 of 5 care plans determined that persons in care (PIC) had been identified as having a significant weight change but there was no documentation to determine if the care plan is reviewed or modified to reflect this change.
Corrective Action(s): Ensure that each care plan is reviewed and if necessary, modified if there is a substantial change in the PIC.
Date to be Corrected: July 9, 2018

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of nutrition and food service documentation found no record of menu audits.
Corrective Action(s): Ensure that documentation respecting food services is complete.
Date to be Corrected: July 9, 2018
Comments

This LO would like to thank the Manger of Care and Staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. 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
Jul 09, 2018
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.