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

VDAN-AF3Q2S

FACILITY NAME Mentmore		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 1081047
FACILITY ADDRESS 523 Mentmore St			FACILITY PHONE (604) 931-6551
CITY Coquitlam	POSTAL CODE V3J 4P5		MANAGER Ashley Mann

INSPECTION DATE October 25, 2016	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4.5
ARRIVAL 09:00 AM	DEPARTURE 01:15 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

This is a scheduled annual Routine Inspection to assess facility compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR). This inspection was scheduled in order to allow the licensee time to arrange sign language interpreters to be present. The inspection took place with the assistance of the facility manager. The Licensing Officer's Reference Guide to Residential Care Database Coding was used to ensure consistency for tis inspection. All ten systems of the Reference Guide were reviewed. A copy of the Reference Guide and an abbreviated checklist for records were left with the manager.

Contraventions

Previous Inspection - Contraventions observed on FIR #VDAN-A5WTVB 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

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31080 - RCR s.16(2)(b) - A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to (b) protect the health and safety of a person using the room. Observation: Lighting was observed in the kitchen where medications are dispensed, there appears to be reduced level of illumination at the counter where medications are prepared. The staff dispensing the medication must stand with there back to the natural light of the window thus shading the area further. The concern presented by this situation is that there will be increased difficulty in ensuring safe dispensing of medication. There were light bulbs observed to be absent from a downstairs bathroom fixture. Corrective Action(s): Please provide a plan that will ensure there is adequate lighting to ensure that staff can easily read medication information for the purpose of safely dispensing medications. Date to be Corrected: Nov. 7, 2016 PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius. Observation: Hot water temperature read 52 degrees Celsius. Corrective Action(s): Please ensure that water temperatures are less than 49 degrees Celsius. Date to be Corrected: Nov. 7, 2016 PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition. Observation: Sanitization of food preparation surfaces is not being done according to directions on the label of the antibacterial spray. This is a repeat contravention. Corrective Action(s): Please provide a plan that will ensure that all staff know that in order to create a germicidal effect for food preparation, the surface must remain wet for the appropriate length of time. Date to be Corrected: Nov. 7, 2016

Comments

The policies and procedures for this facility are consistent with all CLS facilities and were not reviewed at this inspection. A new staff, hired Sept. 15, 2016 had missing documentation requirements such as TB check and Immunization consistent with the BC Program, Food Safe certification, (the person was reported to have taken Food Safe at a previous employer), and evidence of orientation to the CCALA and RCR. Please provide licensing with confirmation that this documentation has been completed. One of the resident's room lighting is extremely subdued. Staff states that the resident complains about bright light and an independent task light would not be appropriate for this resident. The staff indicated that there will be consideration for putting an additional a light in the closet. There is a note above the thermostat that indicates how staff should set the thermostat so as to avoid bothering the south side neighbours with noise. There has been no investigation as to the source of the noise created when the "heat" setting of the thermostat is used. The non-hearing staff are not able to assess the problem. Please provide a plan that will ensure that the source of the noise is not related to a hazard in the heating system. The nutrition system was reviewed. There are audits completed for the spring/summer menu, but not the winter/fall menu. The manager states they will attend the upcoming nutrition planning workshop (tomorrow) before revising and auditing the fall/winter menu. The disaster preparation equipment was reviewed. There was no list observed for anything but the food expiry dates. There was no can opener observed with the canned goods, but in absence of a checklist it could not be determined whether a can opener was included. Other products such as communication devices to enable the non-hearing staff to be aware of the status of the community in the event of a major disaster that might require 3 days preparation before assistance can be expected. Please provide licensing with a plan that will ensure there are all appropriate accommodations as per BC standard for Emergency Preparation. This facility appears well organized, well maintained and clean. The resident rooms reflect their personalities. I'd like to thank the manager, the translators, staff and residents for their assistance with this inspection.

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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