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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-CQDQX4
FACILITY NAME
Mountain View Manor		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962LEH
FACILITY ADDRESS
5800 Mountain View Blvd		FACILITY PHONE
(604) 946-1121
CITY
Delta		POSTAL CODE
V4K 3V6		MANAGER
Jo-Anne Kirk

INSPECTION DATE
March 23, 2023		ADDITIONAL INSP. DATE (multi-day)
March 29, 2023		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6
ARRIVAL
10:30 AM		DEPARTURE
02:30 PM		ARRIVAL
11:00 AM		DEPARTURE
01:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: In review of the care plans for persons in care (PIC), it was noted for 1 PIC that a comprehensive care plan was not in place within 30 days of admission.
Corrective Action(s): Please ensure a comprehensive care plan is in place within 30 days of admission for persons in care.
Date to be Corrected: April 21, 2023

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: In review of weight records for a person in care, it was noted that 2 months were missing a recorded weight.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: April 21, 2023
Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection.

Please provide a response to Licensing by April 21, 2023 as to how the identified contraventions in this report will be addressed. This report was reviewed with the Resident Care Coordinator.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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
Apr 21, 2023
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Click here for a description of each "Category" of violation displayed.