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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

JKAS-CRUVBJ

FACILITY NAME Langley Gardens		SERVICE TYPES 101 Adult Residential Care Facility	FACILITY LICENSE # 0982858
FACILITY ADDRESS 8888 202nd St			FACILITY PHONE (604) 888-0228
CITY Langley	POSTAL CODE V1M 4A7		MANAGER Pamela Nahal

INSPECTION DATE May 15, 2023	ADDITIONAL INSP. DATE (multi-day) May 16, 2023		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 7.25
ARRIVAL 11:30 AM	DEPARTURE 01:45 PM	ARRIVAL 11:00 AM	DEPARTURE 04:00 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 89

Introduction

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 as part of a routine inspection:
- 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.

Visit the CCFL website at https://www.fraserhealth.ca/residentialcare 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

STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Review of 5 staff files determined that 1 of 5 staff has an expired food safe certificate, which is a requirement of their position.
Corrective Action(s): Please obtain copies of any diplomas, certificates or other evidence of the person's training and skills.
Date to be Corrected: May 30, 2023

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: Review of 5 persons in care(PICs) charts found that 1 of 5 PICs has no evidence of immunization records.
Corrective Action(s): Please ensure that all persons admitted comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 30, 2023

RECORDS AND REPORTING: 39410 - RCR s.86(a) - A licensee must keep the following records in respect of each employee: (a) criminal record check results,.
Observation: Review of 5 staff files determined that 1 of 5 staff has an expired Criminal Record Check.
Corrective Action(s): Please keep the following records in respect of each employee: criminal record check results.
Date to be Corrected: May 30, 2023

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: Observation found that the snack cart had more than 2 food groups available for PICs and staff have a copy of breakfast menus they follow, but breakfast and snacks are not listed on the menu.
Corrective Action(s): Please ensure that a record of food services including the menu and menu substitutions are kept.
Date to be Corrected: May 30, 2023

Comments

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

Please provide a written response by May 30, 2023 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was reviewed with the staff on site and signed It was then sent with the corresponding risk assessment to the Manager/ Licensee via email.)

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 May 30, 2023

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