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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-CGYTNR

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
Teresa Guynup

INSPECTION DATE
July 25, 2022
ADDITIONAL INSP. DATE (multi-day)
July 26, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9.5
ARRIVAL
01:00 PM
DEPARTURE
04:30 PM
ARRIVAL
10:30 AM
DEPARTURE
04:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (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
· 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 any noncompliance that was 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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Two spray bottles of chemical cleaners were found stored on the kitchen counter beside the sink.
Corrective Action(s): Please ensure that chemical cleaners are stored securely.
Date to be Corrected: August 19, 2022

POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: Staff manage money and valuables for PICs; however, the Licensee’s policies and procedures do not guide staff concerning the management and monitoring of gift cards held in trust.
Corrective Action(s): Please ensure your policy includes the management and monitoring of gift cards.
Date to be Corrected: August 19, 2022

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: A policy requires staff to record each financial transaction for a PIC in their individual ledger, provide receipts for all purchases made, and record the item(s) purchased in the PICs personal inventory. Staff are also required to use the money allocated for the PICs and not staffs personal money, unless prior approval is granted.
When reviewed, the financial records for four PICs confirmed:
-Not all transactions are documented in the ledgers
-Not all items purchased are entered into personal inventory records
-Not all purchases include receipts from the vendor
-Staff made purchases using their own money, resulting in PICs having to reimburse staff.
Corrective Action(s): Please ensure staff implement policies as required.
Date to be Corrected: August 19, 2022

CARE AND/OR SUPERVISION: 34120 - RCR s.52(1)(a) - A licensee must ensure that a person in care is not, while under the care or supervision of the licensee, subjected to (a) financial abuse, emotional abuse, physical abuse, sexual abuse or neglect as those terms are defined in section 1 of Schedule D.
Observation: Licensing reviewed four PICs records and could not reconcile the accounts as staff made purchases for PICs which PICs were not required to make, transactions occurred that were not recorded and one account had less money than necessary to balance it.
Corrective Action(s): Please provide a written plan to CCFL to ensure Financial Abuse does not occur.
Date to be Corrected: August 19, 2022


Comments

This report was delivered electronically and no signature was collected

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Due Date
Aug 19, 2022
Approximate Follow Up Date

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