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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
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FACILITY NAME
Tall Timbers Residence		SERVICE TYPES
140 Community Living
FACILITY LICENSE #
NNAL-8H9QRY
FACILITY ADDRESS
24156 56th Ave		FACILITY PHONE
(604) 220-4526
CITY
Langley		POSTAL CODE
V2Z 2N9		MANAGER
Lynn Pallot
INSPECTION DATE
October 27, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.25
ARRIVAL
12:00 PM		DEPARTURE
04:15 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
4
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:

- 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
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 (CORRECTED DURING INSPECTION): Review of 2 Persons in Care(PICs) Charts determined that one PIC was missing 2 weights, and the other PIC was missing 4 weights over the last 12 months.
Corrective Action(s): Ensure that each person is weighed at least once each month.
Date to be Corrected:

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: Noted during inspection that a blank substitution list was hanging with the menu, staff were unable to provide evidence that menu substitutions are being documented.
Corrective Action(s): Please ensure that menu substitutions are recorded.
Date to be Corrected: November 10, 2022
Comments

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

Discussion with Supervisor around monthly weights determined that the site purchased a scale in June of 2022, prior to that PICs were taken to other locations to be weighed, which proved a challenge to get monthly weights done.


Please provide a written response by November 10, 2022 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 supervisor on site and signed. It was then forwarded with the corresponding risk assessment to the Licensee 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
Nov 10, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.