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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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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 March 21, 2022	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2.5
ARRIVAL 10:00 AM	DEPARTURE 12:30 PM	ARRIVAL	DEPARTURE	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 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 -

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: 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: Inspection of the physical facility noted: - wood cabinet in the washroom needs repainting - rusty outlets in the shower rooms - mirrors and shelves need replacing due to water damage and age - tub finish is worn and chipped - large crack in the wall next to the tub Corrective Action(s): Ensure all common rooms are maintained in a good state of repair Date to be Corrected: April 4, 2022 POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Review of the emergency procedures noted that although the facility policy requires fire drills to be completed regularly the last one was done July 25 2021 and there is no evidence that PIC's were involved in the education and what type of emergency drill was performed Corrective Action(s): Ensure drills are completed and documented regularly Date to be Corrected: April 4, 2022

Comments

Thank you to the staff and management for their time and support during the routine inspection

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Apr 04, 2022

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