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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CY3TLX

FACILITY NAME
Fort Langley Care Centre
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
SOBA-AFE257
FACILITY ADDRESS
8838 Glover Rd
FACILITY PHONE
(604) 888-0711
CITY
Langley
POSTAL CODE
V1M 2R4
MANAGER
Erick Bautista

INSPECTION DATE
November 30, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
10:15 AM
DEPARTURE
03:15 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 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): Prescribed medication obsverved in a Person in Cares(PICs)medicine cabinet, staff confirmed once medication is applied it is returned to secured medication cart. Management moved the medication to the secured cart during inspection and confirms this will be reviewed with staff at next meeting
Corrective Action(s): Ensure that all medications are safely secured and stored.
Date to be Corrected:

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Review of 5 staff files determined that 1 of 5 files did not have a current performance review completed, which was confirmed by management.
Corrective Action(s): Ensure that the performance of each employee is reviewed regularly, per facility policy. Management has a plan to complete this by corrective date.
Date to be Corrected: December 31, 2023

RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation (CORRECTED DURING INSPECTION): Review of nursing units, 1 nursing unit retained paper copies of PIC charts, which are not current. Of concern, staff access to outdated information for PICs. Management confirmed it is expected that staff use point click care to ensure they are accessing the most current information. Binders were removed from the unit during inspection.
Corrective Action(s): Ensure that all records pertaining to this regulation are current.
Date to be Corrected:


Comments

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

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 management on site and signed and a copy was provided via email

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Dec 31, 2023

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