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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-CA6PNR
FACILITY NAME
Tall Timbers Residence		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
NNAL-8H9QRY
FACILITY ADDRESS
24156 56th Ave		FACILITY PHONE
(604) 220-4526
CITY
Langley		POSTAL CODE
V2Z 2N9		MANAGER
Jessica Turner
INSPECTION DATE
December 29, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:00 AM		DEPARTURE
12:30 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 & 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 at www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact the area Licensing Officer (LO).
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
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 medications and MAR found that one PRN medication had been signed off on the wrong day then was administered to the PIC
Corrective Action(s): Please ensure that all medications that are administered are signed for on the MAR on the day they were administered
Date to be Corrected: Corrected at the time of inspection

POLICIES AND PROCEDURES: 33240 - RCR s.85(1)(c)(i) - A licensee must do all of the following: (c) make all policies and procedures available (i) to employees at all times.
Observation: Review of the medication system found that there were no MSAC meeting minutes or pharmacy policies available on site at the facility
Corrective Action(s): Please ensure that all policies and procedures are available to employees at all times
Date to be Corrected: Jan 12, 2021
Comments

Thank you to the staff and management for their support during the routine inspection at Tall Timbers
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
Dec 29, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.