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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
NTJN-AV2VD5
FACILITY NAME
Bethesda Surrey Home		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0904171
FACILITY ADDRESS
16321 108th Ave		FACILITY PHONE
(604) 581-1858
CITY
Surrey		POSTAL CODE
V3R 6C5		MANAGER
John Rodriguez
INSPECTION DATE
January 15, 2018		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
01:30 PM		DEPARTURE
05:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
As part of the 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 CCFL website at www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604.368.5274 or by email at naomi.tanakajesson@fraserhealth.ca.
Contraventions
Previous Inspection - Contraventions observed on FIR #EJON-AJRT3B have been corrected except for those noted on supplementary pages.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: A review of 4 PIC's monthly weights found that one PIC's weight was not recorded for December 2017 and there was no reason documented for the missing weight. Further discussion with staff determined that this PIC was away on the date that weights are taken.
Corrective Action(s): Ensure that each PIC is weighed at least once each month.
Date to be Corrected: January 31, 2018
Comments

This LO would like to thank the Assistant Manager and staff for their time and assistance in completing this routine inspection.

All areas inspected were found to be in compliance with the Community Care and Assisted Living Act and/or the Residential Care Regulations.

This report was reviewed and discussed. A copy of this report will be mailed to the Licensee.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.
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
Jan 31, 2018
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.