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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Bethayne House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982498
FACILITY ADDRESS
17412 58A Ave
FACILITY PHONE
(604) 574-2484
CITY
Surrey
POSTAL CODE
V3S 1M8
MANAGER
Mariette Roberts

INSPECTION DATE
January 05, 2023
ADDITIONAL INSP. DATE (multi-day)
January 13, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:50 AM
DEPARTURE
10:15 AM
ARRIVAL
10:30 AM
DEPARTURE
01:00 PM
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 except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: One of the PIC room has visible scuff marks on the wall. Leadership is aware and put forth request to have it addressed.
Corrective Action(s): Please ensure all rooms and areas are in a good state of repair.
Date to be Corrected: March 2, 2023

CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Oral hygiene plan had not been reviewed past year for 2 of 3 PIC's care plan.
Corrective Action(s): Pleaes ensure care plan is reviewed and if necessary modified at least once a year.
Date to be Corrected: February 1, 2023


Comments

During the inspection there was discussion regarding ways to protect the flooring from the sofa.
Please provide a written response to the coded violations by January 23, 2023.
Licensing would like to thank the staff for their assistance during the inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jan 23, 2023

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