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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-BDCS4K

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
Gillian Andre

INSPECTION DATE
June 21, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
10:15 AM
DEPARTURE
02:45 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 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: 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: During inspection of the facility it was noted that:
-Through out the home in all rooms and common areas there is significant damages to the walls and door frames from wheelchairs rubbing and hitting the walls and frames.
-In the small bathroom there is water damage to the cabinet under the sink where it meets the floor and the trim along the floor is coming away from the walls
-In the Tub room the base of the hall way door is water damaged
-one bedroom is missing the door kick plate and is damaged
-The kitchen cabinet knobs have worn paint and a few areas on the drawers and cabinets are worn down to wood
-The kitchen window sill is water damaged and missing paint
-Some items from the facilities internal health and safety checklist from last year have not yet been corrected


Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair. The physical facilities concerns were discussed with the manager and many of the items fall under BC housing maintenance. The manager will address the contraventions with BC housing and provide a time line of repair once the manager has received a response from BC housing
Date to be Corrected: July 5, 2019

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: During the inspection it was noted that there was a need for more thorough cleaning through out the home

Interior
- cobwebs in the front entrance window
- inside kitchen cupboards and drawers had food crumbs and dust
- outside of kitchen cupboards were sticky and had food residue
- window sills were dusty
- mops not stored appropriately


Exterior
- side yard maintenance is required
- shed has boards falling off
- exterior of the home is dusty and dirty
- some garbage items to be removed
- hoses left out and are possible tripping hazard


Corrective Action(s): Please ensure the home is maintained in a safe and clean condition.
Date to be Corrected: August 21, 2019

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of the MAR of 2 PIC's showed that the appropriate coding was not being used to document when the PIC was away from the facility
Corrective Action(s): Ensure the proper coding is used on the MAR as per the pharmacy policy
Date to be Corrected: July 5, 2019

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: It was noted that a number of dry food items were stored in open packages
Corrective Action(s): Ensure all food is stored in a safe manner in sealed, labeled containers
Date to be Corrected: July 5, 2019


Comments

Thank you to the staff at Mundy house for their participation and support during the Routine 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
Jul 15, 2019

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