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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JKAS-CW3NH8

FACILITY NAME
Tall Timbers Residence
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
NNAL-8H9QRY
FACILITY ADDRESS
24156 56th Ave
FACILITY PHONE
(604) 220-4526
CITY
Langley
POSTAL CODE
V2Z 2N9
MANAGER
Lynn Pallot

INSPECTION DATE
September 27, 2023
ADDITIONAL INSP. DATE (multi-day)
September 28, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
11:15 AM
DEPARTURE
01:30 PM
ARRIVAL
11:45 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 as part of a routine inspection:
- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting


As part of this routine inspection, a facility risk assessment tool is completed. The risk assessment includes contraventions 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
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of 3 Persons in Care (PICs) medication records determined that in a one month period the effectiveness of 4 PRN medications were not documented.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: October 12, 2023

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation (CORRECTED DURING INSPECTION): During walk through of the home it was found that 1 PIC had 3 of 4 bedrails up on their bed. Review of the PICs chart determined that only upper bed rails are to be used for the PIC.
Corrective Action(s): Please ensure that the care and supervision of a PIC is consistent with the terms and conditions of thier care plan
Date to be Corrected:


Comments

This Licensing Officer would like to thank the Staff for their assistance completing this routine inspection.

Please provide a written response to how the noted contraventions will be addressed by October 12, 2023.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was reviewed with the manager on site and signed by staff. It was then sent to the Manager/ Licensee via email.)

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
Oct 12, 2023

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