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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CKAMLQ
FACILITY NAME
Brydon House		SERVICE TYPES
150 Acquired Injury
FACILITY LICENSE #
JKAG-CEXNTL
FACILITY ADDRESS
20148 50th Ave		FACILITY PHONE
(604)
CITY
Langley		POSTAL CODE
V5X 1A6		MANAGER
Ashley Scott-Dey
INSPECTION DATE
October 17, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.75
ARRIVAL
10:15 AM		DEPARTURE
01:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
6
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: Review of 3 persons in care(PICs) charts determined that 2 of 3 PICs are missing evidence of compliance with the province's immunization control programs.
Corrective Action(s): Please ensure that all persons admitted to a community care facility comply with the Province's immunization and tb control programs.
Date to be Corrected: Nov 1, 2022

RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: During review of 3 PICs charts it was determined that 1 of 3 charts did not have evidence of consent from the PIC to call for medical assistance in case of accident or illness.
Corrective Action(s): Please esure to keep with each PICs record, consent in writing from the PIC or a parent or representative of the person in care
Date to be Corrected: Nov 1, 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 3 PICs charts determined that 2 of 3 PICs were missing evidence of monthly weights(1 pic missing 4 and the other missing 6 weights) over the last 12 months.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: Nov 1, 2022.

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: During inspection it was determined that there was no record of substitutions related to the menu.
Corrective Action(s): Please ensure that a record is kept regarding food services, menus and menu substitions.
Date to be Corrected: Nov 1, 2022.
Comments

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


Please provide a written response by Nov 2, 2022 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, written off-site and forwarded to the Licensee. Therefore no signature was obtained.
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
Nov 01, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.