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

FACILITY NAME
Connect Langley - West House
SERVICE TYPES
150 Acquired Injury
FACILITY LICENSE #
0982780
FACILITY ADDRESS
20433 73A Ave
FACILITY PHONE
(604) 533-9173
CITY
Langley
POSTAL CODE
V2Y 1V1
MANAGER
Ashley Scott-Dey

INSPECTION DATE
September 21, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
10:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation (CORRECTED DURING INSPECTION): During inspection of the exterior of the home a hole was found in the driveway. The hole is approximately 35cm long and 20cm wide and a tree root was protuding from it.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected:

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 3 Persons in Care(PICs) records found that 2 of 3 PICs were missing evidence of monthly weights. 1 PIC was missing 3 of 12 monthly weights and the other PIC was missing 4 of 12 monthly weights.
Corrective Action(s): Ensure that each person is weighed at least once each month.
Date to be Corrected: October 5, 2023

RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: Staff could not provide evidence of documented menu substitutions.
Corrective Action(s): Please ensure that a record of menu substitutions is kept.
Date to be Corrected: October 5, 2023


Comments

The Leadership team has been working on a new, more streamlined system for Performance appraisals, it will be rolled out in October. Plans are in place to complete performance appraisals starting in November. Please ensure that performance appraisals are completed on a regular basis as required.

Discussion with Leadership confirmed that some of the PICs that Connect serves do not always have evidence of childhood vaccinations, in these cases please document this in the PICs care plan.

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

Please provide a written response by October 5, 2023 indicating the corrective actions taken and/or time line and plan for compliance with legislative requirements.

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. A copy will be provided 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 05, 2023

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