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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

JKAS-CN6RQ9

FACILITY NAME Bethesda Langley Home		SERVICE TYPES 104 Specialized Residential Care Home	FACILITY LICENSE # 0982527
FACILITY ADDRESS 20477 93A Ave			FACILITY PHONE (604) 882-7492
CITY Langley	POSTAL CODE V1M 1B8		MANAGER Anne Holden

INSPECTION DATE January 17, 2023	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 12:15 PM	DEPARTURE 04:15 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE 4

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:

- 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

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: Noted upon review of 2 Persons in Care (PICs) charts, 1 of 2 PICs charts does not have evidence of compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Please ensure that all persons admitted to the home comply with he Province's immunization and tuberculosis control programs.
Date to be Corrected: January 31, 2023

NUTRITION AND FOOD SERVICES: 37070 - RCR s.62(2)(c)(iii) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (iii) seasonal variations in food.
Observation: Noted during inspection the home is currently following the 4 week summer menu, this could present a challenge ensuring that the menu can be followed at all times; an example of this being seasonal fruits.
Corrective Action(s): Please ensure that each menu provides a variety of foods, taking into consideration seasonal variations in food.
Date to be Corrected: January 31, 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: Noted during inspection, upon review of 2 persons in care (PICs) charts 1 of 2, PICs was missing evidence of 3 monthly weights over the previous 12 months.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: January 31, 2023

Comments

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

Discussion with the team around audits from meals and more, these will be scanned and sent to Licensing.
Please provide a written response by January 31, 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 Manager on site, signed and a copy provided with the corresponding risk assessment.)

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 Jan 31, 2023

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