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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SYUU-CHNV29

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
August 17, 2022
ADDITIONAL INSP. DATE (multi-day)
August 23, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.75
ARRIVAL
10:30 AM
DEPARTURE
12:45 PM
ARRIVAL
11:00 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 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
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of the menu indicates some of the lunch and dinner does not contain the requirements of containing at least 3 food groups from the Canada Food Guide.
Corrective Action(s): Please ensure all meals contain at least 3 food groups from the Canada Food Guide.
Date to be Corrected: September 23, 2022

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Review of the menu indicates snacks did not always ensure at least 2 food groups from the Canada Food Guide. Weekly basis snack includes cookies from a local grocery store. Licensing discussed that in order for the cookies to meet the requirements of a food group, review the applicable list in the Meals and More.
Corrective Action(s): Please ensure all snack contain at least 2 food groups as described in the Canada Food Guide
Date to be Corrected: September 23, 2022

NUTRITION AND FOOD SERVICES: 37070 - RCR s.62(2)(c)(iii) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (iii) seasonal variations in food.
Observation: Review of the menu completed. The menus did not indicate any separation/differences between seasons.
Corrective Action(s): Please ensure menu takes into consideration of the seasonal variations.
Date to be Corrected: September 23, 2022


Comments

Please provide an action plan to the coded contraventions by September 7, 2022.
This inspection was written off site but discussed with Leadership during the inspection, a copy was sent.
Licensing would like to thank the staff for their assistance during the inspection.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Sep 07, 2022

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