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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CHTV8M

FACILITY NAME
Langley Gardens
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0982858
FACILITY ADDRESS
8888 202nd St
FACILITY PHONE
(604) 888-0228
CITY
Langley
POSTAL CODE
V1M 4A7
MANAGER
Debbie Eglsaer

INSPECTION DATE
August 31, 2022
ADDITIONAL INSP. DATE (multi-day)
September 02, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
11:30 AM
DEPARTURE
02:30 PM
ARRIVAL
10:30 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
92

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/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: 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: Dry spackle was observed on the wall located on the 3rd floor measuring approximately a foot in length and appeared unfinished.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: September 30, 2022

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 1 of 10 PIC's health care plans found no evidence of immunization records.
Corrective Action(s): Ensure that all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: September 30, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Upon inspection of the kitchen on the third floor found pitchers of milk and juice uncovered and without labels. A full jug of milk was observed to be missing its cap and left opened. Butter and sandwiches were covered but without any dates or labels.
Corrective Action(s): Ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: September 30, 2022

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: Review of 2 of 10 PIC's weight charts determined that a weight was not captured for the month of January and March 2022 and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: September 30, 2022


Comments

I would like to thank the team at Langley Gardens for their time and assistance in the completing this inspection. Please submit a written response by September 30, 2022 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements. If you have any questions related to this report please feel free to contact me. Due to infection control practices in place related to COVID-19 prevention, this report was written off-site and is therefore unsigned. The report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Sep 30, 2022

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