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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-CUCQYE
FACILITY NAME
Bethesda Surrey Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0904171
FACILITY ADDRESS
16321 108th Ave
FACILITY PHONE
(
604
)
581-1858
CITY
Surrey
POSTAL CODE
V3R 6C5
MANAGER
John Rodriguez
INSPECTION DATE
August 03, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
10:35 AM
DEPARTURE
01:00 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 & 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
https://www.fraserhealth.ca/residentialcare
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.
Observed Violations
No violations were found during the inspection.
Comments
All areas were found to be in compliance.
Discussion with the Manager regarding balance of allowing PICS to participate in daily activities such as wiping down bathroom area along with access with any chemical cleaning products.
Focused Inspection Bulletin was provided.
This inspection report was reviewed by the Manager, copy to be emailed.
Action Required by Licensee/Manager
Action Required by Licensing Staff
No action required
No action
required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.