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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CFUUE3

FACILITY NAME
Langley Memorial Hospital ECU
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962LHH
FACILITY ADDRESS
22051 Fraser Hwy
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Barbara-Ann Kubb: Hospice and Maple Hill
Chelsea Archer: Cedar and Marrwood South
Joyti Sharma: Rosewood and Marrwood Centre

INSPECTION DATE
June 28, 2022
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.25
ARRIVAL
09:30 AM
DEPARTURE
12:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

Follow-Up Inspection Report

Follow-up to Routine Inspection #AROE-CCBQZZ



An unscheduled follow-up 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 purpose of this inspection is to determine whether the Licensee has taken corrective actions to address the contraventions identified in Routine Inspection #AROE-CCBQZZ.


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: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Inspection of physical facility it is noted that in the servery areas there is a lack of cleanliness with dirty drawers,cupboards and baseboards below.
Corrective Action(s): Ensure all common areas are maintained in a safe clean condition.
Date to be Corrected: July 19, 2022

STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Discussion with management determined that employee performance evaluations are not up to date, the managers are working on a plan as to how best manage evaluations to ensure completion.
Corrective Action(s): Ensure performance of each employee is reviewed regularly.
Date to be Corrected: July 19, 2022


Comments

This Licensing Officer would like to thank the Manager and staff for their assistance in completing this follow-up inspection.

Discussion with management confirms the team is working on a plan for future tub replacement.

This report was written off-site and forwarded to Facility management.

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 19, 2022

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