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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
WCLK-AG8UGE
FACILITY NAME
The Waterford		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0983055
FACILITY ADDRESS
1345 56th St		FACILITY PHONE
(604) 943-5954
CITY
Delta		POSTAL CODE
V4L 2P9		MANAGER
Lara Fares
INSPECTION DATE
December 01, 2016		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.25
ARRIVAL
09:35 AM		DEPARTURE
03:45 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
Introduction

A scheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s(LO)
observations, review of facility records and information provided by facility staff at the time of the inspection.

As part of the Routine Inspection a 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.

A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights.

Visit CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to legislation (CCALA and RCR)
Contraventions
Previous Inspection - Contraventions observed on FIR #WCLK-A3BTSL have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: For 2 persons in care their nutritional care plans documented the requirement of a cut-up texture. During the lunch meal service Licensing observed the one staff providing assistance to both persons in care feeding them food pieces that were larger than the diet standard, which posed a potential choking risk. The Dietitian observed the same concern and confirmed the pieces served were too large.
Corrective Action(s): Please ensure staff are implementing the care plan as prescribed.
Date to be Corrected: Dec.1, 2016
Comments

The Manager has been at the facility for approximately one year and informed Licensing of various changes she has implemented in regards to food service and the addition of an evening recreation programming from 5:30pm-9:30pm. She also demonstrated her self-monitoring systems to review and monitor care provided.

Licensing requests a written response be submitted on or before December describing how the above noted contravention has been appropriately addressed.
A follow-up inspection confirming compliance to the CC&ALA and RCR may be conducted after the compliance plan has been received by Licensing.

Copies of the inspection report and the Risk Assessment Tool were reviewed, discussed, and provided to the Manager. If you have any questions regarding this report please contact your Licensing Officer.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Dec 16, 2016
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.