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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AFCTCY

FACILITY NAME
Bethesda West Clearbrook Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782091
FACILITY ADDRESS
2339 Arbutus St
FACILITY PHONE
(604) 850-7311
CITY
Abbotsford
POSTAL CODE
V2T 2V8
MANAGER
Lorraine Derksen

INSPECTION DATE
November 03, 2016
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:30 AM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA), The Residential Care Regulations (RCR), and the Relevant Director Of Licensing Standard of Practice (DLSP).

Information for this report was gathered based on the licensing observations, review of the facility records, and information provided by the facility manager and staff. The facility file was reviewed for operational history and the Facility Risk Assessment Tool was completed as part of the Routine Inspection and a copy provided to the Licensee.

For resources for licensees, links to the legislation (CCALA and RCR) and Residential Care Facility Inspection Reports posted online, go to: www.fraserhealth.ca/residentialcare.

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
CARE AND/OR SUPERVISION: 34790 - RCR s.83(1)(a) - A licensee of a community care facility with 24 or fewer persons in care must (a) develop a nutrition plan for each person in care.
Observation: Nutrition forms were not completed for all four persons in care. These include the Satisfaction Survey (last completed June 2015), Nutrition Care Plan Checklist, Screening Forms, and Food and Nutrition Form.
Corrective Action(s): Ensure nutrition plan is developed for each person in care.
Date to be Corrected: December 2, 2016

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): Two broths located in non-refrigerated storage and three sauces in the refrigerator were outdated.
Corrective Action(s): Ensure food is safely stored.
Date to be Corrected:

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: There is no documentation of snacks offered on the menus or in other areas. Two persons were assessed by The HSCL dietician no longer requiring an evening snack, while two other persons in care do receive an afternoon snack. Of concern is that an AM snack is not provided for all four persons in care. The food record for the persons in care who does receive an afternoon snack shows she mostly receives a drink in the afternoon.
Corrective Action(s): Ensure the menu provides for each day, at least two nutritious snacks, with each snack containing at least two food groups as per the Canada Food Guide.
Date to be Corrected: December 2, 2016


Comments

The following systems 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


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 02, 2016

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