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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SCLY-BFERCG

FACILITY NAME
Bethesda West Clearbrook Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782091
FACILITY ADDRESS
2339 Arbutus St
FACILITY PHONE
(604) 850-7311
CITY
Abbotsford
POSTAL CODE
V2T 2V8
MANAGER
Lorraine Derksen

INSPECTION DATE
August 26, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
09:45 AM
DEPARTURE
01:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · 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 CCFL website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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 summer menu for week 1 found that on 3 days the breakfast meals consist of 2 food groups.
Corrective Action(s): Please ensure that each meal consists of at least 3 food groups as described in Canada's Food Guide.
Date to be Corrected: Sept. 9, 2019


Comments

Review of 2 person in care's care plans found that there were a couple of documents in each that needed to be reviewed since the previous 1-2 months.

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
Sep 09, 2019

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