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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-CM2NMC

FACILITY NAME
Mundy Street Residence
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
1020005
FACILITY ADDRESS
316 Mundy St
FACILITY PHONE
(604) 931-7123
CITY
Coquitlam
POSTAL CODE
V3K 5M4
MANAGER
Tammy Kirk

INSPECTION DATE
December 08, 2022
ADDITIONAL INSP. DATE (multi-day)
December 13, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
12:15 PM
DEPARTURE
04:00 PM
ARRIVAL
03:45 PM
DEPARTURE
04:15 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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 except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: 1. The PIC's only bathtub is not operational and as per staff assisting with the inspection the tub has been out of order for over 3 months.
2. The lift to assist PIC's into the tub is not operational as well.
Corrective Action(s): Ensure that all equipment for use by person in care are maintained in good state of repair.
Date to be Corrected: Jan 20, 2022

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The following were observed:
1). The PIC's main bathroom door has evidenced rot right across horizontally adjacent to the floor. The staff assisting with the inspection informed the Licensing officer that this damage has been caused by water spills during the shower. The PIC's storage cupboard in this bathroom also has a water damaged base. A hard plastic covering case on the door frame of the washroom door had is damaged 5inches above the floor.

2). The back exit door lock has become loose causing it to stick when trying to open or shut the door. This door also has blinds which is broken and does not fully close.

3). The kitchen counter top has dents and holes near the range. Of concern is the appropriate cleaning and sanitization of the countertop.

Corrective Action(s): Please ensure that all rooms and common areas are maintained in good state of repair. Per the staff person assisting with the inspection, a request has been submitted to the maintenance team for repairs of some of the items.
Date to be Corrected: December 28, 2022

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: One PIC's care plan had not been reviewed after a substantial change in the PIC's circumstances. The staff assisting with the inspection agreed to update the care plan to reflect the change in PIC's situation.

Corrective Action(s): Please ensure PIC care plans are reviewed and modified as appropriate.
Date to be Corrected: December 28, 2022


Comments

The facility has a new manager who has been involved with a number of physical facility and furnishings upgrades. Submitting of appropriate health and safety plans and ensuring the safety of PICs during any renovations have been discussed. This Licensing officer has been informed that the facility will have a detailed health and safety plan for the construction of garden area where almost the entire backyard has been stocked with bricks. Thank you to all the staff for their assistance during this inspection.

Should any further clarification or questions arise regarding this report, please contact your Licensing Officer.

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
Dec 16, 2022

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