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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SCLY-AZERY6

FACILITY NAME
Bethesda Clearbrook Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0704120
FACILITY ADDRESS
32553 Willingdon Cres
FACILITY PHONE
(604) 853-0042
CITY
Abbotsford
POSTAL CODE
V2T 1S1
MANAGER
Marilyn Taylor

INSPECTION DATE
June 01, 2018
ADDITIONAL INSP. DATE (multi-day)
June 04, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
11:00 AM
DEPARTURE
12:00 PM
ARRIVAL
10:30 AM
DEPARTURE
01:45 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine 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 (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 · 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 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 - Contraventions observed on FIR # have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
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: 1 out of 2 Person in Care (PIC) records has an expired consent (expired in 2017) to call a medical and/or nurse practitioner.
Corrective Action(s): Please ensure that each PIC has a current signed consent form to call a medical or nurse practitioner or ambulance in case of accident of illness.
Date to be Corrected: June 18, 2018


Comments


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
Jun 18, 2018

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