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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MMAE-AABSJ5

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 26, 2016
ADDITIONAL INSP. DATE (multi-day)
May 12, 2016
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
01:00 PM
DEPARTURE
04:15 PM
ARRIVAL
02:30 PM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

On May 13, 2016, CCFL conducted an unscheduled inspection of the physical premise as part one of a routine inspection. The Manager was not on site at the time, but it was agreed the supervisor who was present would accompany CCFL. It was agreed CCFL would return on May 19, 2016, to complete the remainder of the inspection, however, this was re scheduled.

The L.O. guide to data base coding was used for this inspection.

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: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: The BBQ tray appears very soiled with charred remains.
Corrective Action(s): Ensure the BBQ is maintained in a safe and clean condition.
Date to be Corrected:

POLICIES AND PROCEDURES: 33210 - RCR s.75(2)(b) - If a restraint is used in an emergency and the use of the restraint continues, either continuously or intermittently, for more than 24 hours, a licensee must (b) comply with the conditions set out in section 73 (2).
Observation: In review of the documentation for one resident, it appears the consent for restraint has not be reassessed (signed) in excess of one year.
Corrective Action(s): Ensure there is a system in place to review/assess the requirement for restraint.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: In review of the documentation for one resident, it appears that the care plan has not been reviewed (or revised) in excess of one year.
Corrective Action(s): Ensure care plans are reviewed (and/or revised) as per the above noted section of legislation.
Date to be Corrected:

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: In review of the records for 1 resident, it appears the weight is not being monitored monthly with no records available for 4 months out of 7(months)
Corrective Action(s): Ensure weight is monitored and recorded as per above.
Date to be Corrected:


Comments

All remaining items as per the above noted guide appear to be in compliance.

On CCFL's return to the facility on 26 May, 2016, the BBQ had been cleaned and a cleaning schedule has been established for the BBQ. Therefore, code 31270 has been addressed.

CCFL would like to thank you for your time and assistance during this inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Approximate Follow Up Date

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