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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-C3FNDR

FACILITY NAME
Waverly Seniors Village
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9ULX
FACILITY ADDRESS
8445 Young Rd
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Suzanne Darling

INSPECTION DATE
May 27, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
01:30 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

A follow up inspection to Routine Inspection JSAT-BYYNLR, dated March 8 & 9, 2021 was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).

The following care systems were reviewed during this inspection:
- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Medication
- Records and reporting

For resources for licensees, links to the Legislation (CCALA and RCR), and Residential Care Facility Inspection Reports posted online go to: www.fraserhealth.ca/residentialcare

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: It was observed that the upstairs dinning area did not have a menu posted.
Corrective Action(s): Ensure each dining area has a menu posted for each weekly period.
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: It was observed that canned goods were being stored on the floor under the pantry shelves, making it difficult to clean. There was also dirt and debris around the area the food was being stored on the floor.
Corrective Action(s): Ensure all food is safely prepared, stored, served and handled.
Date to be Corrected:

RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Staff at the facility were unable to locate or access the menu audits during the inspection.
Corrective Action(s): Ensure records are kept as per the Audits and More, in respect to menu audits.
Date to be Corrected:


Comments

Licensing officer was on site for a follow up inspection to review previous contraventions and confirm that the facility is moving forward with completing the action items on their compliance plan.
The facility was able to show evidence of creating and implementing systems to self-monitor the facility and the care and services provided by it.
The facility is following their compliance plan with the goal of having all action items completed by July 26, 2021.

This report was discussed with the facility management on site, and will be delivered Via e-mail due to Covid-19 precautions and procedures.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceFollow-up Inspection Required
Approximate Follow Up Date

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