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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JBAY-C9NW3F
FACILITY NAME
Meadowbrook		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
HRUN-BD2V7L
FACILITY ADDRESS
12412 Meadowbrook Pl		FACILITY PHONE
(604) 460-1235
CITY
Maple Ridge		POSTAL CODE
V4R 2H6		MANAGER
Andrea Sigurdur
INSPECTION DATE
December 13, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.83
ARRIVAL
11:15 AM		DEPARTURE
03:05 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
3
Introduction

An unscheduled routine inspection was completed to assess compliance with the: Community Care and Assisted Living Act (CCALA), the Residential
Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include:
Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & 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 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).
Contraventions
Previous Inspection - Not Applicable
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: 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: A temperature check of facility water accessible to persons in care found the temperature to be greater than 49° Celsius (a temperature of 52° C was recorded).
Corrective Action(s): Ensure that water accessible to persons in care, from any source, is not heated to more than 49° Celsius.
Date to be Corrected: December 15, 2021

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: A review of admission records found that one out of three persons in care did not have evidence of a tuberculosis screening on file.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: December 21, 2021

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: A review of the facility's menus found no evidence of the results of monitoring of food services and nutrition care (menu audits) for the current menu.
Corrective Action(s): Ensure that a record is kept of the results of monitoring of food services and nutrition care (menu audits).
Date to be Corrected: December 28, 2021
Comments

Facility management was provided with a paper copy of Fraser Health's COVID-19 Prevention Checklist for their reference and/or use.
Please submit a written response by December 28, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.
This inspection report was not signed as it was reviewed with management over the telephone and sent via email to the site to reduce the amount of time the licensing officer had to spend on site as per COVID-19 prevention measures.
Licensing would like to thank facility management and staff for their assistance in completing this inspection.
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 28, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.