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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-BJYMGF

FACILITY NAME
Bethesda Chilcotin Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
SSTN-98LVEZ
FACILITY ADDRESS
32704 Chilcotin Dr.
FACILITY PHONE
(604) 744-5274
CITY
Abbotsford
POSTAL CODE
V2T 5S5
MANAGER
Lorraine Derksen

INSPECTION DATE
December 13, 2019
ADDITIONAL INSP. DATE (multi-day)
December 18, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5
ARRIVAL
09:45 AM
DEPARTURE
01:00 PM
ARRIVAL
09:30 AM
DEPARTURE
10:30 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

As part of the 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 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
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: During review of the facility it was noted that the ottoman in the living-room was missing part of its fabric cover, this has the potential to make it difficult to keep clean and sanitary.
Corrective Action(s): Please ensure that all equipment and furnishings are maintained in a safe and clean condition.
Date to be Corrected: January 6, 2020

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: Review of the physical facility revealed gouges on the corner of the wall leading into the kitchen and along the wall behind the kitchen table which left dry-wall exposed. Staff report it is related to mobility equipment belonging to persons in care (PIC). The shower-room flooring is also in need of repair as the non-slip flooring is beginning to lift in the corner close to the sink. There was also a black substance noted under the silicon caulking which staff indicated was used to previously patch it.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 6, 2020

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Review of 4 bedrooms found that all 4 rooms had packages of incontinence products being stored on the floor of the closets. 1 room also had clothing and blankets resting directly on the floor behind the incontinence products. Of concern is the ability to properly clean and sanitize the floor of the closets. The Sliding door tracks in the laundry/hallway area contain water of an unknown source and in some parts of the track there is a black build-up.
Corrective Action(s): Please ensure that rooms and common areas are maintained in safe and clean conditions.
Date to be Corrected: January 6, 2020

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Review of the kitchen revealed a package of muffin mix stored in the pantry which expired in April of 2019. The pantry also contained 2 large plastic bins used to store flour. Staff report that current process is to dump packaged flour into the plastic bins. The two bins did not have expiration dated noted on them, nor date for when bin was last filled. Staff member was unclear if there was a process to clean and sanitize bins between packages of flour.
Corrective Action(s): Please ensure that food is safely prepared, stored, served and handled.
Date to be Corrected: January 6, 2020

NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Review of the weekly menu audits completed by the facility revealed that they are not meeting the minimum requirement of servings for the week reviewed.
Corrective Action(s): Please ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Date to be Corrected: January 6, 2020


Comments

Licensing would like to thank the Bethesda Chilcotin team for their time and cooperation with the routine inspection.

Licensing has the following recommendations:

Recommend that thickener for fluids as well as a mechanical blender be kept in the emergency supplies to support PIC individual nutrition care plan.
Recommend ensuring that any bottle containing peri-spray be appropriately labelled as to its contents.
Consider reinforcing the corner of the wall leading into the kitchen to prevent further damage once repaired.
Recommend that any mechanical lift stored in hallway have both its brakes engaged when not in use.

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 06, 2020

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