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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-B97R7X

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 08, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
09:45 AM
DEPARTURE
12:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
4

Introduction

An unscheduled routine inspection was conducted in the presence of 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 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/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 except for those noted on supplementary pages.

Observed Violations
RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: A random review of the persons in care charts indicated a few weights were not documented on the computerized system (specifics were provided during the inspection).
Corrective Action(s): Please ensure monthly weights are documented for all the persons in care on a consistent basis.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.


Comments

Medication reviews:

- In discussion with the Manager the medication reviews do occur and the Pharmacist has documentation around this. A general discussion took place and the writer made reference to HPA Bylaw and to have a discussion with the Pharmacist around having the medication reviews completed for the persons in care on-site at the home.

Staff checklist:

- The Licensee is in the process of transferring documentation on-line for the staff. The writer has previously confirmed at all routine inspections that all legislative requirements around staffing have been met.

- The Manager will look into having references, work history (e.g., resume), diplomas/certificates (as examples), and immunizations noted on-line for all the staff.

- The Manager advised the writer that the tuberculosis assessments for the staff are already in process of being transferred to the on-line system.

Please let the writer know by when you have looked into the above and a tentative date of having this completed by.

Thank you for your time to complete this routine inspection. If there are any questions related to this routine inspection report, please contact your Licensing Officer.

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
Feb 28, 2019

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