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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BELQ59

FACILITY NAME
Bethesda Matsqui Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0720048
FACILITY ADDRESS
32768 Bevan Ave
FACILITY PHONE
(604) 850-3499
CITY
Abbotsford
POSTAL CODE
V2S 1T1
MANAGER
Sava Duran

INSPECTION DATE
July 31, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:30 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed include the following:

Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & Reporting
Resident Bill of Rights
Additional CCALA Sections

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).

Contraventions
Previous Inspection - Contraventions observed on FIR #CJOS-B4ZV7N 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: 34570 - RCR s.75(3)(b) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (b) as part of the reassessment, consult, to the extent reasonably practical, with the persons who agreed to the use of the restraint.
Observation: Of 2 persons in care (PIC) records reviewed, both use a restraint. Each PIC had appropriate consents however the reassessment of one was overdue (due May 18, 2019) as required by the careplan which indicated an annual reassessment. Of concern is the restraint consent form only provides space for the facility manager to sign indicating its been reassessed.
Corrective Action(s): Please ensure that as part of the reassessment and to the extent that it is reasonably practical, those who agreed to the consent are consulted as part of the reassessment..
Date to be Corrected: 15 August 2019

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Of 3 PIC records reviewed, 2 did not have immunization records.
Corrective Action(s): Please ensure that all PICs admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: 15 August 2019


Comments

This LO will provide an Immunization Record form to this facility.
Thank you for your assistance with my conducting this inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Aug 15, 2019

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