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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-BM5RWX

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
February 25, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

An unscheduled routine inspection was initiated on February 14, 2020 and the remainder of the inspection was completed on February 25, 2020 with the Manager 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 the 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 website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XUHwhWyos2z for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).

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

Physical Plant:

A random review of the home indicated that the Manager has an on-going maintenance plan in-place. The following the Manager is aware of and/or already in the process of being addressed:

(1) Privacy film in a ensuite washroom needs to be replaced (Please keep the writer updated on this);

(2) There is scratches on the floor due to a person in care moving their furniture and this is being monitored;

(3) Fire extinguisher in the living room by the door the fire extinguisher has been taken off the wall by a person in care (The Manager will put the fire extinguisher back on the wall and monitor this & Please let the writer know when it is mounted back on the wall);

(4) Fencing at the back of the home is currently kept up with braces and BC Housing starting March 12, 2020 will replace the fence in phases taking into consideration health and safety of the person in care (in addition the bushes nearby will be removed). The Manager will keep the writer updated on the progress of this until the work is completed.

Nutrition and Food Services:

- The meals and more checklist and menu checklist have been completed for 2019 and the Manager is in the process of working on the menu audit. Please let the writer know when this is completed.

Thank you for your time to complete today's inspection. If there are any questions, please contact your assigned Licensing Officer.

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

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