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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BDBM8Q

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 20, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
10:00 AM
DEPARTURE
02:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

An unscheduled routine inspection 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 -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
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: It was observed on the menu there were snacks that only consisted of foods from one food group.
Corrective Action(s): Ensure that snacks include foods from at least 2 food groups as described in Canada's food guide.
Date to be Corrected: 28 June 2019


Comments

Information was provided to the facility manager concerning reportable incident forms. CCFL had determined that paper forms will no longer be produced by Fraser Health and as such all facilities will be required to submit reportable incidents online by October 01, 2019. Instructions on how set up the online reporting account will be provided to the manager of Bethesda Clearbrook Home. Presently the Manager signs off on all PIC's personal finances ensuring the reconciliation of funds and expenses. It was suggested by this LO that a second party should provide a second check of personal finances as a measure to decrease a potential risk of error.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Jun 28, 2019

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