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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AXQ2GN

FACILITY NAME
Montgomery House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1081105
FACILITY ADDRESS
227 Montgomery St
FACILITY PHONE
(604) 936-3171
CITY
Coquitlam
POSTAL CODE
V3K 5E7
MANAGER
Kelly Ternes

INSPECTION DATE
April 10, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
01:45 PM
DEPARTURE
05:45 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 feel free to contact me at 604 949 7710

Contraventions
Previous Inspection - Contraventions observed on FIR #VDAN-ALSPQV 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: 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: Toilet in back bedroom had a ring at water level and sediment was observed on toilet bowl below the water line. Toilet was cleaned at inspection
Corrective Action(s): completed
Date to be Corrected: April 10, 2018

STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: A newer employee who is responsible for food preparation, serving and handling has no recorded Food Safe as per staff snapshot.
Corrective Action(s): Please ensure that staff who manage food for residents are appropriately trained.
Date to be Corrected: April 26, 2018

STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Emergency preparation was reviewed. A brown fluid was observed in the first aid kit. It appeared that metal forceps had perforated a cold pack.
Corrective Action(s): Please provide a plan that will ensure that emergency equipment will be maintained in good condition.
Date to be Corrected: April 26, 2018


Comments

This facility is clean and well organized. The residents are seen to be interacting with the staff in a calm and respectful manner. Each resident's room reflects their own personal interests and taste.
The Policies and Procedures were not reviewed at this inspection as they are used by the licensee throughout their facilities ad were checked last month at a sister facility.
Thank you to staff and residents for assistance with this inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Apr 26, 2018

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