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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-C2HMGD

FACILITY NAME
Belmont Residence
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982347
FACILITY ADDRESS
3975 202nd St
FACILITY PHONE
(604) 534-9950
CITY
Langley
POSTAL CODE
V3A 1R9
MANAGER
Teresa Griffiths

INSPECTION DATE
April 20, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:45 AM
DEPARTURE
01:15 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: One of the PIC's lower portion of the door frame is showing signs of wear and tear.
Corrective Action(s): Please ensure all rooms are in good state of repair.
Date to be Corrected: May 28, 2021

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: Effective of one type of PRN has not been recorded. Licensing was informed this was result of the medication being changed from PRN to regular medication. Facility is in the process with having it updated
Corrective Action(s): Please ensure employees follow the Policies and Procedures set up by Medication Safety Safety and Advisory Committee
Date to be Corrected: May 17, 2021

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Some snack menu includes, cookies and yogurt, cheese puffs
Corrective Action(s): Please ensure snacks contain at least 2 food groups
Date to be Corrected: May 30, 2021


Comments

Due to COVID pandemic, the inspection report was written offsite, but was discussed during the time of the inspection.
Please provide a written response to how the coded violations will be addressed by May 13, 2021.
Please ensure the Licensee contact is made aware of the report.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
May 13, 2021

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