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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-BZ9SAH

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
Amanda Tominac

INSPECTION DATE
March 19, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
09:30 AM
DEPARTURE
11:32 AM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

Introduction

An unscheduled routine inspection was conducted in the presence of the Coordinator Adult Residential 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
- 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 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 Community Care Facilities Licensing (CCFL) website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2CWtTpKipp for:
- Additional resources, and
- Links to the legislation (CCALA and RCR).

Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice.

Observed Violations
No violations were found during the inspection.

Comments

All areas inspected during the routine inspection appeared to meet the intent of the legislation. Thank you for your time to complete this routine inspection.
Due to the Covid-19 pandemic, the findings were reviewed with the Coordinator Adult Residential at the time of the inspection. This inspection report, and risk assessment was written off-site and then emailed on March 19, 2021 to the Coordinator Adult Residential for review and to finalize the report and risk assessment once they were in agreement to the wording. As a result of the pandemic, signature for the Coordinator Adult Residential is not included. If there are further questions related to this routine inspection, please contact your Licensing Officer.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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