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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-ANYRSM

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
July 05, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
11:00 AM
DEPARTURE
02:00 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)

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
POLICIES AND PROCEDURES: 33240 - RCR s.85(1)(c)(i) - A licensee must do all of the following: (c) make all policies and procedures available (i) to employees at all times.
Observation: There is no policy available to guide staff to ensure bleach and water solution is appropriate for disinfection and sanitation, including information of length of time for solution is effective. The manager explained that it has been discussed with staff to change the solution weekly and is part of the nightly routine, though when the night routine checklist was reviewed, it was not documented.
Corrective Action(s): Ensure there is policy and procedures to guide staff.
Date to be Corrected: August 4, 2017

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: A Medication Buddy Check has been implemented to decrease medication errors. This form is to be signed 4 times a day. For the first 4 days of July, the form has been signed 3 of 16 times, in addition to one signature observed to be on the wrong date.
Corrective Action(s): Ensure employees are implementing policies.
Date to be Corrected: August 4, 2017

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: 2 of 4 persons in care monthly weights documentation was not completed for the month of June. The manager also reviewed daily logs to see if the information was inputted in this area, but to no avail.
Corrective Action(s): Ensure each person in care is weighed monthly.
Date to be Corrected: August 4, 2017


Comments

Licensing would like to acknowledge:
- Summer menu audits are in the process of being completed by the end of July.
- 2 of 4 Care plans have been reviewed and updated. The manager is in the process of reviewing and revising the remaining 2 by end of August, with any updates required sooner will be completed in a timely manner.
- The Society is updating Emergency Supplies to include a 72 hour food supply kit, and the managers will ensure that all supplies can be adapted for specific diets/ restrictions etc.
- 4 Performance evaluations are in the process of being completed by the end of August.

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
Aug 04, 2017

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