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

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 16, 2024
ADDITIONAL INSP. DATE (multi-day)
January 19, 2024
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.75
ARRIVAL
01:40 PM
DEPARTURE
02:10 PM
ARRIVAL
10:00 AM
DEPARTURE
01:15 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 thfis 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 as part of a routine inspection:
- 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
CARE AND/OR SUPERVISION: 34560 - RCR s.75(3)(a)(ii) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (a) reassess the need for the restraint on the earlier of (ii) the time specified by the persons who agreed.
Observation: Upon review of two persons in care(PICs) charts, it was determined that 1 PICs restraint assessment form was assesed in May of 2022 and the other PICs was assessed in July of 2021; the reassessment frequency is noted to be annually for both of these PICs.
Corrective Action(s): Ensure that if a restraint is used and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must reassess the need for the restraint on the earlier of the time specified by the persons who agreed.
Date to be Corrected: Feb 5, 2024

RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection 77(3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Conversation with the manager regarding reportable incidents and a review of a Person in Care's(PICs) Chart determined that the PIC was sent to Hospital in December of 2023 and this was not reported to CCFL in the manner required.
Corrective Action(s): Ensure that if a person in care is involved in a reportable incident immediately notify a medical health officer, in the form and manner required by the medical health officer.
Date to be Corrected: Feb 5, 2024


Comments

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

A conversation was had around Care Plans and the 4 Persons in Care plans are now overdue, the manager has them scheduled to be done in March of 2024.


Please provide a written response to how the noted contraventions will be addressed by February 5, 2024.

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 and signed. It was then sent to the Manager/ Licensee via email.)

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
Feb 05, 2024

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