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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-AV9RTG

FACILITY NAME
Bethayne House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982498
FACILITY ADDRESS
17412 58A Ave
FACILITY PHONE
(604) 574-2484
CITY
Surrey
POSTAL CODE
V3S 1M8
MANAGER
Michael Macatiag

INSPECTION DATE
January 22, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
09:55 AM
DEPARTURE
12:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
3

Introduction

Introduction
An unscheduled routine inspection was initiated to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR), and the relevant Director of Licensing Standards of Practice (DLSP). 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 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.

Please visit the Community Care Facilities Licensing (CCFL) website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:

* Additional resources, and

* Links to the legislation (CCALA and RCR)





Contraventions
Previous Inspection - Not Applicable
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: - Throughout the home in various locations noted black scuff marks and in some areas where the drywall is showing (white colour), for example outside the office especially at the lower level near the baseboards and corners the paint has chipped off.

- In the washroom near the medication room noted in the sink (white coloured sink) the following:

* Near the drain the paint has chipped off and black coloured area is showing. In addition, on the upper right corner of the sink it appears white coloured paint was put on, however it is starting to come showing a black coloured patch.

- In addition, another portion of the home there are areas on the wall with white patches and the Manager stated that this will be addressed. In this same area, the washroom for example on the ceiling noted with the light fixture cracked.

The Manager stated that there have been discussion with the BC Housing regarding painting and/or putting in wall protection half way down from the walls to prevent ongoing maintenance issues. The Manager stated this is likely to start in February 2018 and the writer will be kept up to date regarding this before moving forward (i.e., health and safety plan will be submitted for the writer's review and approval).
Corrective Action(s): Please ensure all areas of the home are maintained a good state of repair.
Date to be Corrected: Please provide a written response by the timeline noted in this report.


Comments

Thermometers:

In the deep chest freezer when entering the garage through the house and the refrigerator (fridge and freezer) will each have a thermometer (total of 3) put in-place to ensure that the freezers are maintaining a temperature of -18 degrees Celsius or lower and the fridge component(s) are maintaining a temperature of 4 degrees Celsius or lower. The Manager stated they will have this addressed today and will let the writer know when this is addressed via e-mail.

If you have any questions regarding this report, please contact your Licensing Officer.

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
Jan 26, 2018

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