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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-BM4VAW

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
Adele Fussi

INSPECTION DATE
February 25, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2
ARRIVAL
01:00 PM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

A follow up inspection to Routine Inspection SCLY-BG5LTH , dated September 3, 2019, 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:
- Staffing
NOTE: Not all care systems were reviewed during this follow up inspection, as the high risk items were reviewed in detail. Regular monitoring of the facility will continue from Licensing and quality assurance.

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
STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: 1 of 2 new staff hired only showed evidence of one reference check.
Corrective Action(s): Ensure there are character references (more than one) for each staff person.
Date to be Corrected:

STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: 1 of 2 new staff files reviewed did not have evidence of qualifications or training.
Corrective Action(s): Ensure the community care facility has copies of diplomas, certificates, or other evidence of training.
Date to be Corrected:

STAFFING: 32170 - RCR s.42(1)(a) - A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to (a) meet the needs of the persons in care.
Observation: Night staff continue to be short one staff member, Day and evening staff are also short and needs of persons in care are not being met.
Corrective Action(s): Ensure employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern to meet the needs of persons in care.
Date to be Corrected:


Comments

-Currently the count of persons in care is at 41/53
-DOC daily auditing system has been implemented. DOC was scheduled to be off site today and not available to review all self monitoring systems.
-Licensing officer (LO) met with GM to discuss current action plan to address previous contraventions.
-1 new LPN permanent line is now being filled consistently since January 22nd.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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