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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-AZAS9P

FACILITY NAME
Bethesda Langley Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982527
FACILITY ADDRESS
20477 93A Ave
FACILITY PHONE
(604) 882-7492
CITY
Langley
POSTAL CODE
V1M 1B8
MANAGER
John Rodriguez

INSPECTION DATE
May 30, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
10:00 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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: 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: Inspection of 1 of 4 persons in care (PIC) room found that one PIC's medications are stored in a cupboard in their bedroom. The cupboard was did appear to have once had a lock but now that lock was removed.
Corrective Action(s): Ensure that all medications in the facility are safely and securely stored.
Date to be Corrected: June 29, 2018

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: A review of 1 of 4 persons in care (PIC) care plan determined that there were significant changes since January 2018 and that some information contained in the care plan was no longer relevant.
Corrective Action(s): Ensure that care plans are reviewed and if necessary, modified if there is a substantial change in the circumstances of the PIC.
Date to be Corrected: June 29, 2018

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A review of the menu and nutrition documentation determined that there were no records of menu audits or the results of food service monitoring.
Corrective Action(s): Ensure that audits are completed and records are available for review.
Date to be Corrected: June 29, 2018


Comments

This LO would like to thank the Manger and Staff for their time and assistance in completing this routine inspection.

This report was reviewed and discussed with on-site staff. A copy of this report was left at the facility.

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

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Jul 03, 2018

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