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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BYQM93
FACILITY NAME
Bethesda Matsqui Home		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0720048
FACILITY ADDRESS
32768 Bevan Ave		FACILITY PHONE
(604) 850-3499
CITY
Abbotsford		POSTAL CODE
V2S 1T1		MANAGER
Marian VanderBos
INSPECTION DATE
March 01, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM		DEPARTURE
04:00 PM		ARRIVAL
DEPARTURE
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 (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this 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 w ww.fraserhealth.ca/residentialcare for:
· Additional resources, and
· Links to the Legislation (CCALA and 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: A walk through the physical facility noted that the hallway wall corners and bedroom walls have paint chipped off exposing drywall. The manager stated that all persons in care (PIC) use wheelchair in the home resulting in the scratch marks on the walls.
Corrective Action(s): Please ensure that all common areas are maintained in good state of repair
Date to be Corrected:

STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of the 4 medication records (MAR) of persons in care (PIC) noted 1 PIC's MAR had a handwritten dosage of a medication (on yellow sticky note) stuck on the MAR sheet. It was also noted that for 1 PIC's PRN medication result was in appropriately documented as "given" instead of the outcome.
Corrective Action(s): Please ensure that staff comply with the policies and procedures of the MSAC.
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Food items for Persons in care were noted to be stored on the floor in the pantry.
Corrective Action(s): Please ensure that food for the persons in care is safely stored and handled.
Date to be Corrected:


Comments

The Licensing Officer (LO) would like to thank the Manager and the staff for their time and assistance in completing this routine inspection. It was noted that facility has systems in place to monitor provision of care and audit processes. An office chair for staff use in the tub room was noted to be worn out and the leather-like coating was removed and peeling off on the base and the inside back making it difficult to ensure appropriate sanitizing between use. The manager was in the process to replace this chair.

The facility nurse was on site during first hour of the inspection and supervised staff food safe recertification/retraining proceeded as scheduled during the inspection. Renovation work to the fence and retaining wall on the site was observed by Licensing Officer.

This report was reviewed and discussed with manager. 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
Mar 26, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.